Healthcare Provider Details

I. General information

NPI: 1154965622
Provider Name (Legal Business Name): MWAFFAK BASHIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WATERSIDE PROFESSIONAL PARK
PUTNAM VALLEY NY
10579-3502
US

IV. Provider business mailing address

101 WATERSIDE PROFESSIONAL PARK
PUTNAM VALLEY NY
10579-3502
US

V. Phone/Fax

Practice location:
  • Phone: 914-528-7337
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD61266703
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number282308
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: