Provider Demographics
NPI:1770530958
Name:PATHAKJEE, BHARAT Y (MD)
Entity type:Individual
Prefix:DR
First Name:BHARAT
Middle Name:Y
Last Name:PATHAKJEE
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 1:744 S WEBSTER AVE
Mailing Address - Street 2:PO BOX 22425
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-433-3640
Mailing Address - Fax:920-617-2094
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3640
Practice Address - Fax:920-617-2094
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22488-20207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30263600Medicaid
WI30263600Medicaid
000016Medicare Oscar/Certification
WI0001 07265Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
B55621Medicare UPIN