=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003654864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHISH BHARGAVA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2024
-----------------------------------------------------
Last Update Date | 07/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 E BLUFF ST APT 7102
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-475-8826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 E BLUFF ST APT 7102
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-475-8826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------