Healthcare Provider Details

I. General information

NPI: 1285717942
Provider Name (Legal Business Name): DEEPTI JAIN BHASIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEEPTI JAIN BHASIN MD

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 OSIGIAN BLVD SUTIE 400
WARNER ROBINS GA
31088-8988
US

IV. Provider business mailing address

402 OSIGIAN BLVD SUTIE 400
WARNER ROBINS GA
31088-8988
US

V. Phone/Fax

Practice location:
  • Phone: 478-333-3058
  • Fax: 478-333-3496
Mailing address:
  • Phone: 478-333-3058
  • Fax: 478-333-3496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number28166
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number059979
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number059979
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD28166
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: