Provider Demographics
NPI:1770576100
Name:BHATTA, SANJEEV (MD)
Entity type:Individual
Prefix:
First Name:SANJEEV
Middle Name:
Last Name:BHATTA
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 1:803 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-6013
Mailing Address - Country:US
Mailing Address - Phone:352-530-2256
Mailing Address - Fax:352-414-4638
Practice Address - Street 1:803 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6013
Practice Address - Country:US
Practice Address - Phone:352-530-2256
Practice Address - Fax:352-414-4638
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 82971207RC0000X, 207UN0901X
FLME82971207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09012OtherBCBS
FL263891600Medicaid
FL263891600Medicaid
FL09012ZMedicare PIN