Basic Information
| Provider Information | |||||||||
| NPI: | 1477526044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BHARADWAJ | ||||||||
| FirstName: | RAVINDRA | ||||||||
| MiddleName: | MOHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847298 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5939 HARRY HINES BLVD 8TH FLOOR STE HQ08.124 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753901786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 43992 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01056005A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 44727 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | 43992 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | Q2739 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 303346601 | 05 | TX | MEDICAID | BB8022383 | 01 | DEA | OTHER | 20447390 A | 05 | OK | MEDICAID | 01056005A | 01 | IN | STATE LICENSURE | OTHER | 303346602 | 05 | TX | MEDICAID | 200425170A | 05 | IN | MEDICAID | 75152835 | 05 | NM | MEDICAID |