=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720508062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FUAD BASHJAWISH DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2017
-----------------------------------------------------
Last Update Date | 03/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 346 US HIGHWAY 46
-----------------------------------------------------
City | ROCKAWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07866-3815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-686-6055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25212 ECHO LAKE DR
-----------------------------------------------------
City | WHARTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07885-1265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-686-6055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 25MB11163800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------