Provider Demographics
NPI:1588921597
Name:BHATTA, MANGESH (MD)
Entity type:Individual
Prefix:
First Name:MANGESH
Middle Name:
Last Name:BHATTA
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 1:11201 PEONY CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-3440
Mailing Address - Country:US
Mailing Address - Phone:512-766-0670
Mailing Address - Fax:
Practice Address - Street 1:919 E 32ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2703
Practice Address - Country:US
Practice Address - Phone:512-544-4089
Practice Address - Fax:512-544-4435
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9960207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX554621YM8AMedicare PIN