1972589968 NPI number — BIJAN BASTANINEJAD M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972589968 NPI number — BIJAN BASTANINEJAD M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BASTANINEJAD

Provider First Name:

BIJAN

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1972589968

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 1308

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

POPLAR BLUFF

Provider Business Mailing Address State Name:

MO

Provider Business Mailing Address Postal Code:

63902-1308

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

573-843-8380

Provider Business Mailing Address Fax Number:

573-843-8381

Provider First Line Business Practice Location Address:

2620 N WESTWOOD BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

POPLAR BLUFF

Provider Business Practice Location Address State Name:

MO

Provider Business Practice Location Address Postal Code:

63901-3396

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

573-785-7721

Provider Business Practice Location Address Fax Number:

573-727-2465

Provider Enumeration Date:

12/21/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207P00000X , with the licence number:  237324 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X , with the licence number: 35.088489 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208M00000X , with the licence number: 35.088489 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208000000X , with the licence number: 2009039681 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 40113 . This is a "HPM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 02695054 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
• Identifier: 000000488786 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 4920459 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 5202199 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
• Identifier: 7210867 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 05227 . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 2678446 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 237324 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
• Identifier: 000000520832 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".