Healthcare Provider Details

I. General information

NPI: 1023322567
Provider Name (Legal Business Name): PRIYANKA BAWEJA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 ENTERPRISE DR STE 300
LOWELL AR
72745-8982
US

IV. Provider business mailing address

515 ENTERPRISE DR STE 300
LOWELL AR
72745-8982
US

V. Phone/Fax

Practice location:
  • Phone: 479-717-7626
  • Fax: 479-717-7627
Mailing address:
  • Phone: 479-717-7626
  • Fax: 479-717-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036155545
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberE-15863
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: