Provider Demographics
NPI:1730178922
Name:BEZWADA, VISHNU V (MBBS)
Entity type:Individual
Prefix:
First Name:VISHNU
Middle Name:V
Last Name:BEZWADA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 S 14TH AVE UNIT 11
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6285
Mailing Address - Country:US
Mailing Address - Phone:617-272-5589
Mailing Address - Fax:
Practice Address - Street 1:2045 S 14TH AVE UNIT 11
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6285
Practice Address - Country:US
Practice Address - Phone:617-272-5589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219720207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2065240Medicaid
I11972Medicare UPIN
MA2065240Medicaid