Provider Demographics
NPI:1114159399
Name:UPRETY, SUBODH BHAKTA (MD)
Entity type:Individual
Prefix:MR
First Name:SUBODH
Middle Name:BHAKTA
Last Name:UPRETY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:130 DESIARD STREET
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7363
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2408 BROADMOOR BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2963
Practice Address - Country:US
Practice Address - Phone:318-807-0525
Practice Address - Fax:318-807-1107
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD205649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1887358Medicaid
LA330445YJBUMedicare PIN