Basic Information
| Provider Information | |||||||||
| NPI: | 1720429319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAHETI | ||||||||
| FirstName: | DEEPTI | ||||||||
| MiddleName: | RAMESH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.B.B.S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1470 | ||||||||
| Address2: | |||||||||
| City: | EAGLE PASS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788531470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8307738917 | ||||||||
| FaxNumber: | 8307731892 | ||||||||
| Practice Location | |||||||||
| Address1: | 4018 EL INDIO HWY | ||||||||
| Address2: | |||||||||
| City: | EAGLE PASS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788526690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106019000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R4664 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 368297 | 01 | TX | AMERICAN BOARD INTERNAL MEDICINE | OTHER | 3824179-01 | 05 | TX | MEDICAID |