Provider Demographics
NPI:1487649836
Name:MOHAPATRA, BASANTA K (MD)
Entity Type:Individual
Prefix:
First Name:BASANTA
Middle Name:K
Last Name:MOHAPATRA
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 1:3622 BELMONT AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1450
Mailing Address - Country:US
Mailing Address - Phone:330-759-9350
Mailing Address - Fax:330-759-9387
Practice Address - Street 1:3622 BELMONT AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1450
Practice Address - Country:US
Practice Address - Phone:330-759-9350
Practice Address - Fax:330-759-9387
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078344M207L00000X
OH35078344207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2215132Medicaid
OH2215132Medicaid
OHH25883Medicare UPIN