Basic Information
Provider Information | |||||||||
NPI: | 1467632521 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BHAGWANDIN | ||||||||
FirstName: | VIMLA | ||||||||
MiddleName: | PRAVENI | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6908 PROVIDENCE PARK DR S | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366954600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516603490 | ||||||||
FaxNumber: | 2516603491 | ||||||||
Practice Location | |||||||||
Address1: | 6908 PROVIDENCE PARK DR S | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366954600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516603490 | ||||||||
FaxNumber: | 2516603491 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2007 | ||||||||
LastUpdateDate: | 10/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 28261 | AL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 515-45281 | 01 |   | BLUE CROSS AND BLUE SHIELD OF ALABAMA | OTHER | 631500075 | 05 | AL |   | MEDICAID | 510I37000 | 01 | AL | MEDICARE PECOS | OTHER |