Healthcare Provider Details

I. General information

NPI: 1932143005
Provider Name (Legal Business Name): SUSHAMA BHARGAVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-4301
  • Fax:
Mailing address:
  • Phone: 479-443-4301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number2004010777
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: