Healthcare Provider Details

I. General information

NPI: 1780889618
Provider Name (Legal Business Name): BALA BHAGAVATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BALASUBRAMANIAN BHAGAVATH

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2365 DEMING WAY
MIDDLETON WI
53562-5512
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-824-6160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number72546-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number267127
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberMD12320
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: