Provider Demographics
NPI:1063581551
Name:DAMERA, BHASKAR R (MD)
Entity type:Individual
Prefix:
First Name:BHASKAR
Middle Name:R
Last Name:DAMERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E TORRANCE AVE
Mailing Address - Street 2:PO BOX 768
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-2748
Mailing Address - Country:US
Mailing Address - Phone:815-844-6109
Mailing Address - Fax:815-844-3561
Practice Address - Street 1:151 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523-1206
Practice Address - Country:US
Practice Address - Phone:217-362-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45418Medicare UPIN
IL673091Medicare ID - Type Unspecified