Provider Demographics
NPI:1194742668
Name:ODEDRA-MISTRY, BHANU (MD)
Entity type:Individual
Prefix:
First Name:BHANU
Middle Name:
Last Name:ODEDRA-MISTRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 GOLD DR S STE 101
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6413
Mailing Address - Country:US
Mailing Address - Phone:701-280-2033
Mailing Address - Fax:701-232-5578
Practice Address - Street 1:1707 GOLD DR S STE 101
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6413
Practice Address - Country:US
Practice Address - Phone:701-280-2033
Practice Address - Fax:701-232-5578
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I21456Medicare UPIN