Provider Demographics
NPI:1417204363
Name:BATH, KHUSHBIR (MD)
Entity type:Individual
Prefix:
First Name:KHUSHBIR
Middle Name:
Last Name:BATH
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 1:20100 N 51ST AVE STE F620
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5084
Mailing Address - Country:US
Mailing Address - Phone:623-376-6328
Mailing Address - Fax:623-566-6454
Practice Address - Street 1:20100 N 51ST AVE STE F620
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5084
Practice Address - Country:US
Practice Address - Phone:623-376-6328
Practice Address - Fax:623-566-6454
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65159207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ157052Medicaid