Provider Demographics
NPI:1801877725
Name:BHAGAVATH, SUDHAKAR SHIVARAO III
Entity type:Individual
Prefix:DR
First Name:SUDHAKAR
Middle Name:SHIVARAO
Last Name:BHAGAVATH
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 COLLINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4736
Mailing Address - Country:US
Mailing Address - Phone:631-549-0919
Mailing Address - Fax:
Practice Address - Street 1:1690 PITKIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5605
Practice Address - Country:US
Practice Address - Phone:718-485-8038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136695208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00442306Medicaid
NY00442306Medicaid