Provider Demographics
NPI:1639497514
Name:BHALALA, MITESH S (MD)
Entity Type:Individual
Prefix:
First Name:MITESH
Middle Name:S
Last Name:BHALALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:189 QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2967
Mailing Address - Country:US
Mailing Address - Phone:508-588-6700
Mailing Address - Fax:508-584-3010
Practice Address - Street 1:35 SUMMER ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-3469
Practice Address - Country:US
Practice Address - Phone:508-821-4100
Practice Address - Fax:508-822-2367
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA266145207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110118206AMedicaid