Healthcare Provider Details

I. General information

NPI: 1144207143
Provider Name (Legal Business Name): BASAVARAJAPPA VISWANATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E BROAD ST SUITE #209
ELYRIA OH
44035-6400
US

IV. Provider business mailing address

24701 EUCLID AVE THIRD FLOOR BILLING SERVICES
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 440-329-7320
  • Fax: 440-329-7319
Mailing address:
  • Phone: 440-329-7320
  • Fax: 440-329-7319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-044261
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35-044261
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: