Provider Demographics
NPI:1023189818
Name:BHATT, SHASHANK (MD)
Entity Type:Individual
Prefix:
First Name:SHASHANK
Middle Name:
Last Name:BHATT
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 1:1001 W FAYETTE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2866
Mailing Address - Country:US
Mailing Address - Phone:315-937-3026
Mailing Address - Fax:315-937-3126
Practice Address - Street 1:182 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2545
Practice Address - Country:US
Practice Address - Phone:315-218-7020
Practice Address - Fax:315-218-7050
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429491207R00000X
NY264293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02920556Medicaid
PA101966081Medicaid
PA111877Medicare PIN
PA101966081Medicaid
NYP00636892Medicare PIN