1053316067 NPI number — FAWAD H WALAJAHI M.D.

Table of content: FAWAD H WALAJAHI M.D. (NPI 1053316067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053316067 NPI number — FAWAD H WALAJAHI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALAJAHI
Provider First Name:
FAWAD
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053316067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1272
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71613-1272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-535-7457
Provider Business Mailing Address Fax Number:
870-535-2522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 W 40TH AVE
Provider Second Line Business Practice Location Address:
STE 2B
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71603-6957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-535-7457
Provider Business Practice Location Address Fax Number:
870-535-2522
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  R3423 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 55444 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 050019322 . This is a "RAILROAD MEDICARE/PGBA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103071001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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