Provider Demographics
NPI:1114968377
Name:BHATT, KUSUMAKAR RAGHUVIR (DO)
Entity Type:Individual
Prefix:DR
First Name:KUSUMAKAR
Middle Name:RAGHUVIR
Last Name:BHATT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:303 S MAIN ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2189
Mailing Address - Country:US
Mailing Address - Phone:574-254-0800
Mailing Address - Fax:574-254-0812
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:855-855-2792
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-08-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN02001763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200145060AMedicaid
IN08018211Medicare PIN
ING55436Medicare UPIN
IN187670FMedicare PIN