Basic Information
| Provider Information | |||||||||
| NPI: | 1568458438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANERJEE | ||||||||
| FirstName: | BHASKAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 N CAMPBELL AVE | ||||||||
| Address2: | ROOM 6402 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857245028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206266119 | ||||||||
| FaxNumber: | 5208747133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 N CAMPBELL AVE | ||||||||
| Address2: | ROOM 6402 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857245028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206266119 | ||||||||
| FaxNumber: | 5208747133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 01/31/2012 | ||||||||
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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 | 207RG0100X | 109364 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 208076117 | 05 | MO | MEDICAID |