Provider Demographics
NPI:1982302386
Name:BAKSHI, VIDAL (CST, CSFA)
Entity type:Individual
Prefix:
First Name:VIDAL
Middle Name:
Last Name:BAKSHI
Suffix:
Gender:M
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3222 GROVE MEADOWS CV
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-3459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6325 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-5775
Practice Address - Country:US
Practice Address - Phone:678-474-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA215334246ZC0007X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant