Provider Demographics
NPI:1356834741
Name:BAVISHI, CHANAKYA (DO)
Entity Type:Individual
Prefix:
First Name:CHANAKYA
Middle Name:
Last Name:BAVISHI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 E LAUREL RD STE 1700
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-566-7010
Mailing Address - Fax:856-566-6956
Practice Address - Street 1:42 E LAUREL RD STE 1700
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-7010
Practice Address - Fax:856-566-6956
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11945800204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM