Healthcare Provider Details

I. General information

NPI: 1336336064
Provider Name (Legal Business Name): BHARGAVA CHANDRA PULIPATI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST STE 205
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

475 E MAIN ST STE 205
PATCHOGUE NY
11772-3121
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-2386
  • Fax: 631-447-3852
Mailing address:
  • Phone: 631-654-2386
  • Fax: 631-447-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2502711
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: