Provider Demographics
NPI:1609834415
Name:BAVIBIDILA, BERTHOLLET M (MD)
Entity Type:Individual
Prefix:
First Name:BERTHOLLET
Middle Name:M
Last Name:BAVIBIDILA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:WILSON BLDG
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-338-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00027212601OtherUNIVERA
NY11121577OtherCAQH
NY110242022OtherMEDICARE RAILROAD
NYP010203530OtherBLUE CHOICE
NY00355266Medicaid
NY101660BJOtherPREFERRED CARE
NY1245OtherSIDNEY HILLMAN
NY051006000001OtherFIDELIS
NY0414023OtherIHA