Healthcare Provider Details

I. General information

NPI: 1114014958
Provider Name (Legal Business Name): SHASHIKANT BHAILAI BHAVSAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 TRINTY LANE
OCEANA WV
24870-0400
US

IV. Provider business mailing address

37456 COAL RIVER RD
WHITESVILLE WV
25209-0217
US

V. Phone/Fax

Practice location:
  • Phone: 304-682-6246
  • Fax: 304-682-4543
Mailing address:
  • Phone: 304-854-1323
  • Fax: 304-854-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11044
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: