Provider Demographics
NPI:1568458438
Name:BANERJEE, BHASKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:BHASKAR
Middle Name:
Last Name:BANERJEE
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 1:1501 N CAMPBELL AVE
Mailing Address - Street 2:ROOM 6402
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5028
Mailing Address - Country:US
Mailing Address - Phone:520-626-6119
Mailing Address - Fax:520-874-7133
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:ROOM 6402
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-5028
Practice Address - Country:US
Practice Address - Phone:520-626-6119
Practice Address - Fax:520-874-7133
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109364207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208076117Medicaid
010810183Medicare PIN
E67041Medicare UPIN
100014498Medicare PIN