Healthcare Provider Details

I. General information

NPI: 1457649709
Provider Name (Legal Business Name): AMIT S BHAKOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

2115 CRYSTAL GROVE DR
LAKELAND FL
33801-6875
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1100
  • Fax:
Mailing address:
  • Phone: 863-688-2334
  • Fax: 863-581-8812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME150712
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE-10871
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301109496
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME150712
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: