Healthcare Provider Details

I. General information

NPI: 1710257316
Provider Name (Legal Business Name): ANUPA MANDAVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY STE 3323
LOUISVILLE KY
40217-1415
US

IV. Provider business mailing address

1169 EASTERN PKWY STE 3323
LOUISVILLE KY
40217-1415
US

V. Phone/Fax

Practice location:
  • Phone: 718-300-1540
  • Fax:
Mailing address:
  • Phone: 718-300-1540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number50737
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number50737
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: