Basic Information
| Provider Information | |||||||||
| NPI: | 1811906555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHATOYA | ||||||||
| FirstName: | JAGDEV | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BHATOYA | ||||||||
| OtherFirstName: | JAGDEV | ||||||||
| OtherMiddleName: | RAJ | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W BROWN ST | ||||||||
| Address2: | |||||||||
| City: | WAUPUN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539631702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268332 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 34203 | WI | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 34203 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11014110 | 05 | WI | MEDICAID | BB3699660 | 01 | DEA NUMBER | OTHER | 390848401050 | 01 | WI | ANTHEM | OTHER | 1326349135 | 01 | WI | CMH SB NPI | OTHER | 1851477913 | 01 | WI | NPI CMH | OTHER | 31964300 | 05 | WI | MEDICAID |