Provider Demographics
NPI:1760806285
Name:VISHNU BEZWADA PC
Entity Type:Organization
Organization Name:VISHNU BEZWADA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VISHNU
Authorized Official - Middle Name:V
Authorized Official - Last Name:BEZWADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-272-5589
Mailing Address - Street 1:PO BOX 6935
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2545
Mailing Address - Country:US
Mailing Address - Phone:617-272-5589
Mailing Address - Fax:
Practice Address - Street 1:2400 S AVENUE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7127
Practice Address - Country:US
Practice Address - Phone:617-272-5589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2065240Medicaid
MA2065240Medicaid