Healthcare Provider Details

I. General information

NPI: 1255994901
Provider Name (Legal Business Name): AMJAD PANICKAVEETTIL MOHAMED BASHEER MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 W 69TH ST
SIOUX FALLS SD
57108-8148
US

IV. Provider business mailing address

UCONN GRADUATE MEDICAL EDUCATION 263 FARMINGTON AVENUE LM068
FARMINGTON CT
06030-1921
US

V. Phone/Fax

Practice location:
  • Phone: 605-977-5000
  • Fax: 605-977-5377
Mailing address:
  • Phone: 860-879-4763
  • Fax: 860-879-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number17325
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: