Provider Demographics
NPI:1235163056
Name:BHASKAR, RENUKA (MD)
Entity Type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:BHASKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JACOBSSEN DR STE B
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5516
Mailing Address - Country:US
Mailing Address - Phone:309-451-1123
Mailing Address - Fax:309-451-1212
Practice Address - Street 1:105 KRISPY KREME DR
Practice Address - Street 2:STE 4
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3751
Practice Address - Country:US
Practice Address - Phone:309-585-2837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107260207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1942501978OtherBLUECROSSBLUE SHIELD O
IL1467751156Medicaid
IL1467751156Medicaid