Basic Information
| Provider Information | |||||||||
| NPI: | 1972515716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANGERA | ||||||||
| FirstName: | DIVAKAR | ||||||||
| MiddleName: | SYDNEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 EOFF ST | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042348663 | ||||||||
| FaxNumber: | 3042348960 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 U S ROUTE 250 | ||||||||
| Address2: | |||||||||
| City: | ADENA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439017925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405463338 | ||||||||
| FaxNumber: | 7405464661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 05/26/2015 | ||||||||
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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 | 208D00000X | 35041700 | OH | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0368776 | 05 | OH | MEDICAID | 0049907000 | 05 | WV | MEDICAID | P00126806 | 01 | OH | RAILROAD MEDICARE | OTHER |