Provider Demographics
NPI:1518452648
Name:BHAGAVAN, SACHIN MARITHAMMANAHALLI (MBBS, MD)
Entity Type:Individual
Prefix:
First Name:SACHIN
Middle Name:MARITHAMMANAHALLI
Last Name:BHAGAVAN
Suffix:
Gender:M
Credentials:MBBS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 SERVICE RD STE B401
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7013
Mailing Address - Country:US
Mailing Address - Phone:517-432-9277
Mailing Address - Fax:
Practice Address - Street 1:788 SERVICE RD STE B401
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7013
Practice Address - Country:US
Practice Address - Phone:517-432-9277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018022151207R00000X
MO20220148022084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine