Basic Information
| Provider Information | |||||||||
| NPI: | 1922268176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHUMKAR | ||||||||
| FirstName: | NISHITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BHUMKAR | ||||||||
| OtherFirstName: | NISHITA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 N 10TH PL | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980570009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253915700 | ||||||||
| FaxNumber: | 4253915701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2008 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125988 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD60940610 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1922268176 | 05 | WA | MEDICAID |