Provider Demographics
NPI:1114910908
Name:BHADRA, SHAMIK (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAMIK
Middle Name:
Last Name:BHADRA
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 1:2149 E WARNER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3495
Mailing Address - Country:US
Mailing Address - Phone:480-393-0309
Mailing Address - Fax:480-610-6189
Practice Address - Street 1:3114 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:323-726-3868
Practice Address - Fax:323-726-3870
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ949662Medicaid
CAWA124360Medicaid
I37642Medicare UPIN
AZ949662Medicaid
CAWA124360Medicaid