Basic Information
| Provider Information | |||||||||
| NPI: | 1710295464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BHAT | ||||||||
| FirstName: | PRASHANTH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE #54701 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095586600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25455 BARTON RD STE 204B | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095586600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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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 | 207Q00000X | L-2947 | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C142712 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1710295464 | 05 | CA | MEDICAID | 0 653 669 2 | 01 | AL | ECFMG | OTHER |