Provider Demographics
NPI:1205399383
Name:BHAKTA, PUNITKUMAR (OD)
Entity Type:Individual
Prefix:
First Name:PUNITKUMAR
Middle Name:
Last Name:BHAKTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 VENICE RD APT 5308
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211-7020
Mailing Address - Country:US
Mailing Address - Phone:210-386-4455
Mailing Address - Fax:
Practice Address - Street 1:3800 S ZARZAMORA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78225-2118
Practice Address - Country:US
Practice Address - Phone:210-386-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-07
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ALS-E94-TA-C47152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program