Provider Demographics
NPI:1528244597
Name:GURRAM, BHASKAR (MD)
Entity type:Individual
Prefix:
First Name:BHASKAR
Middle Name:
Last Name:GURRAM
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:P.O. BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-648-3903
Mailing Address - Fax:214-648-2481
Practice Address - Street 1:5323 HARRY HINES BOULEVARD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-648-3903
Practice Address - Fax:214-648-2481
Is Sole Proprietor?:No
Enumeration Date:2008-01-21
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090411208000000X
WI53886208000000X, 2080P0206X
TXQ36832080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528244597Medicaid
WI1528244597Medicaid
WI73601 2049Medicare PIN