Provider Demographics
NPI:1578550026
Name:RADHAKRISHNA, BHARATH (MD)
Entity Type:Individual
Prefix:
First Name:BHARATH
Middle Name:
Last Name:RADHAKRISHNA
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-541-7500
Mailing Address - Fax:239-541-7501
Practice Address - Street 1:2441 SURFSIDE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-3861
Practice Address - Country:US
Practice Address - Phone:239-541-7500
Practice Address - Fax:239-541-7501
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041076207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047789300Medicaid
FL110098335Medicare PIN
FL047789300Medicaid