Healthcare Provider Details

I. General information

NPI: 1174880496
Provider Name (Legal Business Name): JAY M BHATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LA VETA AVE STE 640
ORANGE CA
92868-4306
US

IV. Provider business mailing address

1010 W LA VETA AVE STE 640
ORANGE CA
92868-4306
US

V. Phone/Fax

Practice location:
  • Phone: 715-633-4020
  • Fax:
Mailing address:
  • Phone: 715-633-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberDR0058490
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA126898
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberDR0058490
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberA126898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: