Provider Demographics
NPI:1033162052
Name:BHADJA, KANTILAL N (M D)
Entity Type:Individual
Prefix:
First Name:KANTILAL
Middle Name:N
Last Name:BHADJA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 W AZEELE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3577
Mailing Address - Country:US
Mailing Address - Phone:813-251-0194
Mailing Address - Fax:813-254-0279
Practice Address - Street 1:3010 W AZEELE ST STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3577
Practice Address - Country:US
Practice Address - Phone:813-251-0194
Practice Address - Fax:813-254-0279
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48738207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL083738OtherAVMED PROVIDER ID
FL04608OtherBLUE SHIELD ID
FL0622095OtherAETNA PROVIDER#
FL207373OtherWELLCARE PROVIDER ID
FL061105100OtherMEDIPASS ID#
FL047380400Medicaid
FL401123811OtherCIGNA PROVIDER ID
FLME487378OtherFLORIDA MEDCIAL LICENSE #