Provider Demographics
NPI:1104055094
Name:BHATT, RADHESHYAM (MD)
Entity type:Individual
Prefix:DR
First Name:RADHESHYAM
Middle Name:
Last Name:BHATT
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 1:10201 SE MAIN ST
Mailing Address - Street 2:STE 29
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2937
Mailing Address - Country:US
Mailing Address - Phone:503-261-4475
Mailing Address - Fax:503-261-4476
Practice Address - Street 1:12 EXECUTIVE PARK NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329
Practice Address - Country:US
Practice Address - Phone:404-712-7533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD184150207RP1001X
PAMD446566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0308544Medicaid
PA102762326Medicaid
NJ0308544Medicaid