Provider Demographics
NPI:1982804969
Name:PURUSHOTTAM, BHASKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:BHASKAR
Middle Name:
Last Name:PURUSHOTTAM
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 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTN MSS
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7350
Mailing Address - Country:US
Mailing Address - Phone:267-516-5143
Mailing Address - Fax:
Practice Address - Street 1:4150 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6022
Practice Address - Country:US
Practice Address - Phone:605-755-4300
Practice Address - Fax:605-755-1027
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT189705390200000X
SD9505207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program