Healthcare Provider Details

I. General information

NPI: 1972589968
Provider Name (Legal Business Name): BIJAN BASTANINEJAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2879 JAMES BLVD
POPLAR BLUFF MO
63901-3395
US

IV. Provider business mailing address

110 S 2ND ST
ELLINGTON MO
63638-9400
US

V. Phone/Fax

Practice location:
  • Phone: 573-712-1610
  • Fax: 573-776-6124
Mailing address:
  • Phone: 573-663-2313
  • Fax: 573-663-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009039681
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: