Healthcare Provider Details

I. General information

NPI: 1629334859
Provider Name (Legal Business Name): SEJAL BAVISHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 WISCONSIN AVE NW DEPARTMENT OF PEDIATRICS
WASHINGTON DC
20016-2143
US

IV. Provider business mailing address

145 CENTURY DR APT 5404
ALEXANDRIA VA
22304-5791
US

V. Phone/Fax

Practice location:
  • Phone: 201-407-3935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD043202
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: