Provider Demographics
NPI:1780889618
Name:BHAGAVATH, BALA (MD)
Entity type:Individual
Prefix:
First Name:BALA
Middle Name:
Last Name:BHAGAVATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BALASUBRAMANIAN
Other - Middle Name:
Other - Last Name:BHAGAVATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2365 DEMING WAY
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-5512
Practice Address - Country:US
Practice Address - Phone:608-824-6160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72546-20207VE0102X
NY267127207VE0102X
RIMD12320207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03508014Medicaid
J400079965Medicare PIN