Healthcare Provider Details

I. General information

NPI: 1356832331
Provider Name (Legal Business Name): SOURABH BIDHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date: 03/08/2019
Reactivation Date: 04/05/2019

III. Provider practice location address

2460 CURTIS ELLIS DR
ROCKY MOUNT NC
27804-2237
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 828-456-7311
  • Fax: 252-962-3320
Mailing address:
  • Phone: 318-626-0287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number327372
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number327372
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: