Provider Demographics
NPI:1144207143
Name:VISWANATH, BASAVARAJAPPA (MD)
Entity Type:Individual
Prefix:DR
First Name:BASAVARAJAPPA
Middle Name:
Last Name:VISWANATH
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 1:24701 EUCLID AVE
Mailing Address - Street 2:THIRD FLOOR BILLING SERVICES
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:440-329-7320
Mailing Address - Fax:440-329-7319
Practice Address - Street 1:125 E BROAD ST
Practice Address - Street 2:SUITE #209
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6400
Practice Address - Country:US
Practice Address - Phone:440-329-7320
Practice Address - Fax:440-329-7319
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-044261208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
080117615OtherRAILROAD MEDICARE
OH0429478Medicaid
C01834Medicare UPIN
OH0429478Medicaid