Healthcare Provider Details

I. General information

NPI: 1750348025
Provider Name (Legal Business Name): GAGANDEEP SINGH BAJWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINS DR
MODESTO CA
95358-6400
US

IV. Provider business mailing address

4643 BROADWAY
SALIDA CA
95368-9308
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-1750
  • Fax: 209-576-1768
Mailing address:
  • Phone: 209-204-8942
  • Fax: 209-576-1768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA90262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: