Provider Demographics
NPI:1568650935
Name:BHANTI, PRAMOD (PT)
Entity Type:Individual
Prefix:
First Name:PRAMOD
Middle Name:
Last Name:BHANTI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LOUIS AVE
Mailing Address - Street 2:P.O. BOX 577
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-1403
Mailing Address - Country:US
Mailing Address - Phone:631-878-1771
Mailing Address - Fax:631-878-3319
Practice Address - Street 1:5 UNION AVE
Practice Address - Street 2:OM PROFESSIONAL CENTER SUITE 1
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-3323
Practice Address - Country:US
Practice Address - Phone:631-878-1771
Practice Address - Fax:631-878-3319
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86691174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ54302Medicare PIN