Healthcare Provider Details

I. General information

NPI: 1053327536
Provider Name (Legal Business Name): BALRAJ BAWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 COLONY RD
MADISON HEIGHTS VA
24572-2105
US

IV. Provider business mailing address

2705 FARMINGTON PL
LYNCHBURG VA
24503-2921
US

V. Phone/Fax

Practice location:
  • Phone: 434-947-6320
  • Fax: 434-947-2906
Mailing address:
  • Phone: 434-384-8228
  • Fax: 434-947-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101028762
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: