Healthcare Provider Details

I. General information

NPI: 1225074826
Provider Name (Legal Business Name): SHIWAJI DATTATRAY PAWAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 IRON POINT RD
FOLSOM CA
95630-8707
US

IV. Provider business mailing address

2155 IRON POINT RD
FOLSOM CA
95630-8707
US

V. Phone/Fax

Practice location:
  • Phone: 916-817-5438
  • Fax: 916-817-5415
Mailing address:
  • Phone: 916-817-5438
  • Fax: 916-817-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301072268
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: