Healthcare Provider Details

I. General information

NPI: 1508817107
Provider Name (Legal Business Name): RAGHUBINDER K BAJWA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 BLUE HILLS AVE SUITE 103
HARTFORD CT
06112
US

IV. Provider business mailing address

490 BLUE HILLS AVE
HARTFORD CT
06112
US

V. Phone/Fax

Practice location:
  • Phone: 608-714-2647
  • Fax: 608-714-8517
Mailing address:
  • Phone: 608-714-2647
  • Fax: 860-714-8517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29145
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number60569
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: