Provider Demographics
NPI:1073769493
Name:BISTA, BINOD (MD)
Entity Type:Individual
Prefix:
First Name:BINOD
Middle Name:
Last Name:BISTA
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 1:902 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-2438
Mailing Address - Country:US
Mailing Address - Phone:256-216-9777
Mailing Address - Fax:
Practice Address - Street 1:902 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2438
Practice Address - Country:US
Practice Address - Phone:256-216-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine