Provider Demographics
NPI:1386704419
Name:DEVANAGONDI, BHASKAR (MD)
Entity type:Individual
Prefix:MR
First Name:BHASKAR
Middle Name:
Last Name:DEVANAGONDI
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 1:2110 16TH ST 1
Mailing Address - Street 2:BAY PEDIATRIC CLINIC
Mailing Address - City:BAY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-892-2517
Mailing Address - Fax:989-892-4860
Practice Address - Street 1:2110 16TH ST 1
Practice Address - Street 2:BAY PEDIATRIC CLINIC
Practice Address - City:BAY
Practice Address - State:MI
Practice Address - Zip Code:48708
Practice Address - Country:US
Practice Address - Phone:989-892-2517
Practice Address - Fax:989-892-4860
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBD049357174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI350Z96028OtherBLUE CROSS
MI3500941021OtherHEALTH PLUS
MI1821116Medicaid