Healthcare Provider Details

I. General information

NPI: 1528500634
Provider Name (Legal Business Name): SUMJIT BAJWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 N 59TH AVE STE 106
GLENDALE AZ
85304-1239
US

IV. Provider business mailing address

3919 FOX GLEN DR
ANN ARBOR MI
48108-5011
US

V. Phone/Fax

Practice location:
  • Phone: 602-865-7467
  • Fax:
Mailing address:
  • Phone: 734-657-9714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005021
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002613
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: