Provider Demographics
NPI:1083640528
Name:BHAKTA, DIVYESH R (MD)
Entity Type:Individual
Prefix:
First Name:DIVYESH
Middle Name:R
Last Name:BHAKTA
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:502-891-8338
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31873207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000057058YOtherHUMANA - NCVA
KY50000584OtherPASSPORT PIN
KYP00893023OtherRAILROAD MEDICARE - NCVA
KY000000290262OtherANTHEM PIN
KY000000693029OtherANTHEM - NCVA
KY64036544Medicaid
IN200423300FMedicaid
IN200423300AMedicaid
KY2442264000OtherPASSPORT ADVANTAGE
KY060071396Medicare PIN
KY000000290262OtherANTHEM PIN
IN200423300AMedicaid
KY0558216Medicare PIN
KY0558319Medicare PIN
KY50000584OtherPASSPORT PIN
KY000000693029OtherANTHEM - NCVA
KYP00893023OtherRAILROAD MEDICARE - NCVA
KY0713011Medicare PIN
KY0558520Medicare PIN
KY2442264000OtherPASSPORT ADVANTAGE
KY000057058YOtherHUMANA - NCVA
KY64036544Medicaid
KY0259839Medicare PIN