Basic Information
| Provider Information | |||||||||
| NPI: | 1427031145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DASS | ||||||||
| FirstName: | BHAGWAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 219 BAYBERRY DR | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325782353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305196403 | ||||||||
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| Practice Location | |||||||||
| Address1: | 307 BOATNER RD STE 114 | ||||||||
| Address2: | |||||||||
| City: | EGLIN AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325421302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
| FaxNumber: | 8508838635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME106428 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35080329D | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | ME106428 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 001978300 | 05 | FL | MEDICAID | 2331408 | 05 | OH | MEDICAID |