Provider Demographics
NPI:1083791792
Name:BHALLA, SARMISTHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SARMISTHA
Middle Name:
Last Name:BHALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W PROMENADE ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2719
Mailing Address - Country:US
Mailing Address - Phone:573-582-1234
Mailing Address - Fax:573-582-1212
Practice Address - Street 1:321 W PROMENADE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2719
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:573-582-1212
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090032202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1083791792Medicaid