Provider Demographics
NPI:1669492724
Name:BHAKTA, KETAN GOKAL (MD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:GOKAL
Last Name:BHAKTA
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 1:18111 BROOKHURST ST
Mailing Address - Street 2:STE 6300
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-847-6727
Mailing Address - Fax:714-847-6643
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:STE 6300
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-847-6727
Practice Address - Fax:714-847-6643
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG081186207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G811860Medicaid
CAG81186AMedicare PIN
CAG81186Medicare PIN
CAG28593Medicare UPIN