Provider Demographics
NPI:1902836216
Name:BHATT, GIRISH R (MD)
Entity Type:Individual
Prefix:
First Name:GIRISH
Middle Name:R
Last Name:BHATT
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 1:2360 KATY LN
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2300
Mailing Address - Country:US
Mailing Address - Phone:573-785-0080
Mailing Address - Fax:573-785-0811
Practice Address - Street 1:2360 KATY LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2300
Practice Address - Country:US
Practice Address - Phone:573-785-0080
Practice Address - Fax:573-785-0811
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE45822086S0129X
MO20040296302086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159436001Medicaid
AR5N522Medicare ID - Type UnspecifiedINDIVIDUAL #
AR5F526Medicare ID - Type UnspecifiedGROUP #
AR159436001Medicaid