Provider Demographics
NPI:1972761112
Name:BHAKTHAVATSALAM, HEMAVATHY (MD)
Entity Type:Individual
Prefix:
First Name:HEMAVATHY
Middle Name:
Last Name:BHAKTHAVATSALAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10415 MATEO TRL
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-9397
Mailing Address - Country:US
Mailing Address - Phone:718-930-9893
Mailing Address - Fax:
Practice Address - Street 1:1600 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6913
Practice Address - Country:US
Practice Address - Phone:817-848-2708
Practice Address - Fax:817-848-4579
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5572207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217120904Medicaid
TXTXB136699Medicare PIN