Provider Demographics
NPI:1346501699
Name:MUDDA, BHARGAV (MD)
Entity Type:Individual
Prefix:DR
First Name:BHARGAV
Middle Name:
Last Name:MUDDA
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 1:1120 W AVENUE M4
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-1432
Mailing Address - Country:US
Mailing Address - Phone:661-480-2377
Mailing Address - Fax:661-480-2378
Practice Address - Street 1:420 S. SCHMIDT ROAD
Practice Address - Street 2:STE. 240
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2634
Practice Address - Country:US
Practice Address - Phone:630-312-4505
Practice Address - Fax:630-312-6651
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036143270207L00000X, 261QM1300X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty