Provider Demographics
NPI:1801328042
Name:BHAKTA, PRIYA (MD)
Entity type:Individual
Prefix:
First Name:PRIYA
Middle Name:
Last Name:BHAKTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5640
Mailing Address - Country:US
Mailing Address - Phone:773-665-6237
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2023-10-12
Deactivation Date:2022-07-15
Deactivation Code:
Reactivation Date:2022-08-03
Provider Licenses
StateLicense IDTaxonomies
OH35145071208600000X
390200000X
IL036.153552208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363366652OtherEIN