Provider Demographics
NPI: | 1336250596 |
---|---|
Name: | MOHAPATRA, SABYASACHI (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SABYASACHI |
Middle Name: | |
Last Name: | MOHAPATRA |
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: | 7211 N MAIN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | DAYTON |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45415-2566 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 952-846-7090 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 100 HOSPITAL LN STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | DANVILLE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46122-1993 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-745-7310 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-31 |
Last Update Date: | 2024-01-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | L5469 | 207RG0100X |
OH | 35.129724 | 207RG0100X |
IN | 01083437A | 207RG0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 143702201 | Medicaid | |
TX | 8970M0 | Other | BCBS |
TX | 8790M0 | Medicare ID - Type Unspecified | MEDICARE - ODESSA |
G13219 | Medicare UPIN | ||
TX | 8970M0 | Other | BCBS |