MEDICARE: DR. SUDHAKAR SHIVARAO BHAGAVATH III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	136695	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801877725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUDHAKAR SHIVARAO BHAGAVATH III

Provider Business Mailing Address
First Line	:	15 COLLINGWOOD DR
Second Line	:
City	:	HUNTINGTON STATION
State	:	NY
Zip	:	11746-4736
Country	:	US
Telephone Number	:	631-549-0919
Fax Number	:

Provider Business Practice Location Address
First Line	:	1690 PITKIN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-5605
Country	:	US
Telephone Number	:	718-485-8038
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	07/08/2007

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