Provider Demographics
NPI:1871590679
Name:BAHRAINWALA, MURTUZA H (MD)
Entity type:Individual
Prefix:
First Name:MURTUZA
Middle Name:H
Last Name:BAHRAINWALA
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 1:509 LUCAS LN
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-8978
Mailing Address - Country:US
Mailing Address - Phone:217-791-5071
Mailing Address - Fax:
Practice Address - Street 1:509 LUCAS LN
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535-8978
Practice Address - Country:US
Practice Address - Phone:217-791-5071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503973Medicaid
NV100503973Medicaid
NVI21147Medicare UPIN