1225074826 NPI number — SHIWAJI DATTATRAY PAWAR M.D.

Table of content: (NPI 1477600914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225074826 NPI number — SHIWAJI DATTATRAY PAWAR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAWAR
Provider First Name:
SHIWAJI
Provider Middle Name:
DATTATRAY
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:
1225074826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2155 IRON POINT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLSOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95630-8707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-817-5438
Provider Business Mailing Address Fax Number:
916-817-5415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 IRON POINT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-8707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-817-5438
Provider Business Practice Location Address Fax Number:
916-817-5415
Provider Enumeration Date:
06/21/2006

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: 208000000X , with the licence number:  4301072268 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1225074826 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200000021644 . This is a "PHP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3502900692 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4711870-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0990418 . This is a "HEALTHPLUS COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1014600 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1006816 . This is a "MCLAREN HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4306770-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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