Healthcare Provider Details

I. General information

NPI: 1104168269
Provider Name (Legal Business Name): AMIT ISHWAR BHAVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 W WATERTOWN PLANK RD DEPARTMENT OF PSYCHIATRY & BEHAVIORAL MEDICINE
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

8701 W WATERTOWN PLANK RD DEPARTMENT OF PSYCHIATRY & BEHAVIORAL MEDICINE
MILWAUKEE WI
53226-3548
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-8998
  • Fax: 414-955-6299
Mailing address:
  • Phone: 414-955-8998
  • Fax: 414-955-6299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number62680-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number62680-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: