Basic Information
| Provider Information | |||||||||
| NPI: | 1487649836 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOHAPATRA | ||||||||
| FirstName: | BASANTA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3622 BELMONT AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445051450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307599350 | ||||||||
| FaxNumber: | 3307599387 | ||||||||
| Practice Location | |||||||||
| Address1: | 3622 BELMONT AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445051450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307599350 | ||||||||
| FaxNumber: | 3307599387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 03/09/2011 | ||||||||
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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 | 207L00000X | 35078344M | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 35078344 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2215132 | 05 | OH | MEDICAID |