Provider Demographics
NPI:1417506106
Name:BHATNAGAR, ABHINAV
Entity Type:Individual
Prefix:
First Name:ABHINAV
Middle Name:
Last Name:BHATNAGAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2633
Mailing Address - Country:US
Mailing Address - Phone:419-522-2619
Mailing Address - Fax:419-525-6723
Practice Address - Street 1:31 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1262
Practice Address - Country:US
Practice Address - Phone:419-525-6797
Practice Address - Fax:419-525-6723
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026245122300000X
MADN1858495122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0414535Medicaid