Provider Demographics
NPI:1730146499
Name:MAHANTI, ROBERT L (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:MAHANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31012
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-1012
Mailing Address - Country:US
Mailing Address - Phone:928-779-7000
Mailing Address - Fax:
Practice Address - Street 1:900 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3236
Practice Address - Country:US
Practice Address - Phone:928-779-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20847207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0380480OtherBLUE CROSS BLUE SHIELD
1659445062OtherGROUP NPI
180022943OtherMEDICARE RAILROAD
110510OtherAPIPA
DG6643OtherMEDICARE RAILROAD GROUP
AZ110510Medicaid
290066OtherMEDICAID GROUP
110510OtherAPIPA
180022943OtherMEDICARE RAILROAD