Basic Information
| Provider Information | |||||||||
| NPI: | 1518952373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHAKOO | ||||||||
| FirstName: | MANU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 16455 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852116455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809620511 | ||||||||
| FaxNumber: | 4809620523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 S IDAHO RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852196496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808891234 | ||||||||
| FaxNumber: | 4808891235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 06/16/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 24302 | OK | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 37865 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200050810A | 05 | OK | MEDICAID | 300232 | 05 | AZ | MEDICAID | 7738422 | 01 | OK | AETNA | OTHER |