1740268317 NPI number — M IHTESHAM JANJUA MD

Table of content: M IHTESHAM JANJUA MD (NPI 1740268317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740268317 NPI number — M IHTESHAM JANJUA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANJUA
Provider First Name:
M IHTESHAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
IHTESHAM
Provider Other First Name:
MOHAMMAD
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740268317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 E TULPEHOCKEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19144-2030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-438-3047
Provider Business Mailing Address Fax Number:
215-438-3042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3774 RIDGE PIKE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
COLLEGEVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19426-3169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-489-3330
Provider Business Practice Location Address Fax Number:
610-489-9390
Provider Enumeration Date:
01/04/2006

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: 2084P0800X , with the licence number:  MD062987L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0017593790003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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