Basic Information
| Provider Information | |||||||||
| NPI: | 1346501699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUDDA | ||||||||
| FirstName: | BHARGAV | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 W AVENUE M4 | ||||||||
| Address2: | |||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935511432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614802377 | ||||||||
| FaxNumber: | 6614802378 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 S. SCHMIDT ROAD | ||||||||
| Address2: | STE. 240 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604402634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303124505 | ||||||||
| FaxNumber: | 6303126651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2012 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036143270 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 261QM1300X | 036143270 | IL | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 207LP2900X | 036143270 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.