Basic Information
| Provider Information | |||||||||
| NPI: | 1497903447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAJJAR | ||||||||
| FirstName: | BHAVESH | ||||||||
| MiddleName: | ARVINDBHAI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234397280 | ||||||||
| FaxNumber: | 4234397314 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 N STATE OF FRANKLIN RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234397238 | ||||||||
| FaxNumber: | 4234397314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 066037 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD57748 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 066037 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | MD57748 | TN | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 003112853 | 05 | GA | MEDICAID |