Healthcare Provider Details

I. General information

NPI: 1700079787
Provider Name (Legal Business Name): PRATIKSHA DEENESH BHALEEYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 01/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 E 32ND ST
SILVER CITY NM
88061-7215
US

IV. Provider business mailing address

50 DEY ST UNIT # 355
JERSEY CITY NJ
07306-5149
US

V. Phone/Fax

Practice location:
  • Phone: 214-907-2687
  • Fax: 214-907-2687
Mailing address:
  • Phone: 214-907-2687
  • Fax: 214-907-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME108822
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: