Provider Demographics
NPI:1235131152
Name:SOMANATH, BIDARKOTE (MD)
Entity Type:Individual
Prefix:
First Name:BIDARKOTE
Middle Name:
Last Name:SOMANATH
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 1:140 GRANDVIEW AVE
Mailing Address - Street 2:SUITE NO 206
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2505
Mailing Address - Country:US
Mailing Address - Phone:203-753-6413
Mailing Address - Fax:
Practice Address - Street 1:140 GRANDVIEW AVE
Practice Address - Street 2:SUITE NO 206
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2505
Practice Address - Country:US
Practice Address - Phone:203-753-6413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037034208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001370345Medicaid
H03274Medicare UPIN
CT001370345Medicaid