Provider Demographics
NPI:1497918627
Name:PUCHAKAYALA, BHARAT K (MD)
Entity Type:Individual
Prefix:
First Name:BHARAT
Middle Name:K
Last Name:PUCHAKAYALA
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 1:6431 FANNIN ST STE 4.156
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-7375
Mailing Address - Fax:
Practice Address - Street 1:1740 W 27TH ST STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1435
Practice Address - Country:US
Practice Address - Phone:713-500-7375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS3047207RG0100X, 207RG0100X
WI51972207R00000X
IL036123986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX846432OtherMEDICARE PTAN
ILCH2763OtherMEDICARE ID - RRMEDICARE
GA003191968IMedicaid
IL05000342OtherMEDICARE ID - TYPE UNSPECIFIED
IL1245429380OtherMEDICARE NPI - GROUP
IL215379Medicare PIN