Basic Information
Provider Information | |||||||||
NPI: | 1932361011 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BHAKTA | ||||||||
FirstName: | DIPESHBHAI | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BHAKTA | ||||||||
OtherFirstName: | DIPESH | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D, | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PHR GROUP PROVIDER ENROLLMENT UNIT | ||||||||
Address2: | 393 E WALNUT ST FL 3 | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911880001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8776080044 | ||||||||
FaxNumber: | 8775140903 | ||||||||
Practice Location | |||||||||
Address1: | 8080 PARKWAY DR | ||||||||
Address2: |   | ||||||||
City: | LA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 919422104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6193140914 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2008 | ||||||||
LastUpdateDate: | 11/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A111625 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.