Basic Information
| Provider Information | |||||||||
| NPI: | 1114910908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHADRA | ||||||||
| FirstName: | SHAMIK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803930309 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Practice Location | |||||||||
| Address1: | 3114 W BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237263868 | ||||||||
| FaxNumber: | 3237263870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A124360 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 949662 | 05 | AZ | MEDICAID | WA124360 | 05 | CA | MEDICAID |