Provider Demographics
NPI:1316992639
Name:VAIDYA-TANK, BHAVNA (MD)
Entity type:Individual
Prefix:
First Name:BHAVNA
Middle Name:
Last Name:VAIDYA-TANK
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 1:5420 WADE PARK BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4188
Mailing Address - Country:US
Mailing Address - Phone:919-851-2174
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:2076 NC HIGHWAY 42 W
Practice Address - Street 2:STE. 230
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5302
Practice Address - Country:US
Practice Address - Phone:919-553-5711
Practice Address - Fax:919-553-5712
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891372VMedicaid
NC138WAOtherBCBS
NC2027098BMedicare ID - Type Unspecified
NC891372VMedicaid