Basic Information
Provider Information | |||||||||
NPI: | 1174714299 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVE | ||||||||
FirstName: | BHAVIKA | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 141 HALSTEAD AVE | ||||||||
Address2: | STE 304 | ||||||||
City: | MAMARONECK | ||||||||
State: | NY | ||||||||
PostalCode: | 105432652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019842538 | ||||||||
FaxNumber: | 6018151854 | ||||||||
Practice Location | |||||||||
Address1: | 55 FRUIT STREET | ||||||||
Address2: | MASSACHUSETTS GENERAL HOSPITAL | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177265518 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2007 | ||||||||
LastUpdateDate: | 02/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 748-L | MS | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | L-231641 | MA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 20733 | MS | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | P00785631 | 01 |   | RAILROAD MEDICARE | OTHER | P01206953 | 01 | MS | RAILROAD MEDICARE | OTHER |