Provider Demographics
NPI:1265498778
Name:BHATTACHARYYA, DEBASISH (MD)
Entity type:Individual
Prefix:DR
First Name:DEBASISH
Middle Name:
Last Name:BHATTACHARYYA
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 1:800 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53530-1228
Mailing Address - Country:US
Mailing Address - Phone:608-776-4466
Mailing Address - Fax:608-776-5716
Practice Address - Street 1:800 CLAY ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1228
Practice Address - Country:US
Practice Address - Phone:608-776-5748
Practice Address - Fax:608-776-5719
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0878602084N0400X
IL036-1395262084N0400X, 208VP0014X
WI52689-20208VP0014X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100004125Medicaid
IL036139526001Medicaid
I62899Medicare UPIN
WI100004125Medicaid
WIK400282309Medicare PIN