Healthcare Provider Details

I. General information

NPI: 1629094263
Provider Name (Legal Business Name): PURUSHOTHAM BHAGAVATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 LONE TREE WAY
ANTIOCH CA
94509-6200
US

IV. Provider business mailing address

PO BOX 255849
SACRAMENTO CA
95865-5849
US

V. Phone/Fax

Practice location:
  • Phone: 925-779-7276
  • Fax:
Mailing address:
  • Phone: 916-854-6975
  • Fax: 916-854-6864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA49681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: