Provider Demographics
NPI:1881659209
Name:BEDMUTHA, SHANTIKUMAR D (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTIKUMAR
Middle Name:D
Last Name:BEDMUTHA
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 1:176 HALSTON PKWY
Mailing Address - Street 2:
Mailing Address - City:E AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1890
Mailing Address - Country:US
Mailing Address - Phone:716-636-5877
Mailing Address - Fax:716-439-6264
Practice Address - Street 1:176 HALSTON PKWY
Practice Address - Street 2:
Practice Address - City:E AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-1890
Practice Address - Country:US
Practice Address - Phone:716-636-5877
Practice Address - Fax:716-439-6264
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147852-1207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00011395901OtherUNIVERA
NY01561462Medicaid
10136630OtherFIDELIS
000525091012OtherBLUE SHIELD OF WESTERN NY
145801FFOtherPREFERRED CARE
300097080OtherRAILROAD MEDICARE
000524500002OtherBLUE SHIELD OF WESTERN NY
040426001647OtherFIDELIS
NYR1478521OtherWORKERS COMPENSATION
00026885902OtherUNIVERA
00525091015OtherBLUE SHIELD OF WESTERN NY
300081886OtherRAILROAD MEDICARE
000525091013OtherBLUE SHIELD OF WESTERN NY
1609861OtherINDEPENDENT HEALTH
P00003643OtherRAILROAD MEDICARE
NYP00080950OtherMEDICARE RAILROAD
NYP00080950OtherMEDICARE RAILROAD
000525091012OtherBLUE SHIELD OF WESTERN NY
300097080OtherRAILROAD MEDICARE
10136630OtherFIDELIS
NY01561462Medicaid