Healthcare Provider Details

I. General information

NPI: 1659654465
Provider Name (Legal Business Name): MINI BHASKAR MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3168 BRAVERTON ST 330
EDGEWATER MD
21037-2674
US

IV. Provider business mailing address

PO BOX 12333
BELFAST ME
04915-4014
US

V. Phone/Fax

Practice location:
  • Phone: 410-956-3090
  • Fax: 410-956-3063
Mailing address:
  • Phone: 443-481-6480
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: MINI BHASKAR
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 443-481-6464