Provider Demographics
NPI:1205137403
Name:IYENGAR, BASHYAM (MD)
Entity type:Individual
Prefix:
First Name:BASHYAM
Middle Name:
Last Name:IYENGAR
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 1:1760 EDGEWOOD AVE W STE B
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-7209
Mailing Address - Country:US
Mailing Address - Phone:904-358-8480
Mailing Address - Fax:904-358-8460
Practice Address - Street 1:1760 EDGEWOOD AVE W STE B
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-7209
Practice Address - Country:US
Practice Address - Phone:904-358-8480
Practice Address - Fax:904-358-8460
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110643207Q00000X
NJ25MA08303600207Q00000X
NY255281-1207Q00000X
WAMD60189759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008479700Medicaid
GA003130827AMedicaid
FL14P8ZOtherBCBS
FLHA612ZMedicare PIN