Provider Demographics
NPI:1285862144
Name:BISTA, DIPESH RAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:DIPESH
Middle Name:RAJ
Last Name:BISTA
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 1:1400 8TH AVE RM 770
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4110
Mailing Address - Country:US
Mailing Address - Phone:817-922-1770
Mailing Address - Fax:817-922-1775
Practice Address - Street 1:1400 8TH AVE RM 770
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4110
Practice Address - Country:US
Practice Address - Phone:817-922-1770
Practice Address - Fax:817-922-1775
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3149208M00000X, 207R00000X
PAMT195059390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program