Provider Demographics
NPI:1871553222
Name:BAJWA, IMRAN MUSHTAQ (MD)
Entity type:Individual
Prefix:DR
First Name:IMRAN
Middle Name:MUSHTAQ
Last Name:BAJWA
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 1:9473 OLD ROUTE 56 HWY W
Mailing Address - Street 2:
Mailing Address - City:SHELOCTA
Mailing Address - State:PA
Mailing Address - Zip Code:15774-8605
Mailing Address - Country:US
Mailing Address - Phone:724-726-9670
Mailing Address - Fax:
Practice Address - Street 1:850 HOSPITAL RD
Practice Address - Street 2:SUITE 2400
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3662
Practice Address - Country:US
Practice Address - Phone:724-349-8825
Practice Address - Fax:724-349-8826
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052043L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014812010010Medicaid
PAIM075438Medicare ID - Type Unspecified
PA0014812010010Medicaid