=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780772319
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DHARMENDRA N. BHAKTA P.A.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7725 N 43RD AVE STE 111
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85051-5775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-463-8556
-----------------------------------------------------
Fax | 623-463-6654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7725 N 43RD AVE STE 111
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85051-5775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-463-8556
-----------------------------------------------------
Fax | 623-463-6654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2465
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------