Provider Demographics
NPI:1356832331
Name:BIDHAN, SOURABH (MD)
Entity type:Individual
Prefix:
First Name:SOURABH
Middle Name:
Last Name:BIDHAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-626-0287
Mailing Address - Fax:
Practice Address - Street 1:2460 CURTIS ELLIS DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2237
Practice Address - Country:US
Practice Address - Phone:828-456-7311
Practice Address - Fax:252-962-3320
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2025-03-10
Deactivation Date:2019-03-08
Deactivation Code:
Reactivation Date:2019-04-05
Provider Licenses
StateLicense IDTaxonomies
LA327372208M00000X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine