Provider Demographics
NPI:1962610956
Name:BHOOPAL, JAIDEV R (MD)
Entity type:Individual
Prefix:
First Name:JAIDEV
Middle Name:R
Last Name:BHOOPAL
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 1:400 E 3RD ST
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0648207R00000X
MN55855207R00000X, 208M00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962610956Medicaid
MN0004-0018721OtherMEDICA
MN1962610956Medicaid
TX1975229-01Medicaid
TX1975229-01Medicaid
TX8L3399Medicare PIN