Healthcare Provider Details

I. General information

NPI: 1518952373
Provider Name (Legal Business Name): MANU BHAKOO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S IDAHO RD SUITE 206
APACHE JUNCTION AZ
85219-6496
US

IV. Provider business mailing address

PO BOX 16455
MESA AZ
85211-6455
US

V. Phone/Fax

Practice location:
  • Phone: 480-889-1234
  • Fax: 480-889-1235
Mailing address:
  • Phone: 480-962-0511
  • Fax: 480-962-0523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24302
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37865
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: