Provider Demographics
NPI:1396792404
Name:BHOPALE, SHASHIKANT G (MD)
Entity type:Individual
Prefix:
First Name:SHASHIKANT
Middle Name:G
Last Name:BHOPALE
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:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-0340
Mailing Address - Country:US
Mailing Address - Phone:315-732-9368
Mailing Address - Fax:315-732-9403
Practice Address - Street 1:33 E 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1112
Practice Address - Country:US
Practice Address - Phone:315-343-0405
Practice Address - Fax:315-343-5162
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192912-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01467972Medicaid
F64900Medicare UPIN