Provider Demographics
NPI:1053480475
Name:BAWA, VIKAS S (DPM)
Entity Type:Individual
Prefix:DR
First Name:VIKAS
Middle Name:S
Last Name:BAWA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NJ
Mailing Address - Zip Code:08022-2248
Mailing Address - Country:US
Mailing Address - Phone:973-906-3344
Mailing Address - Fax:
Practice Address - Street 1:1060 BROAD ST
Practice Address - Street 2:LOWER LEVEL MEDICAL OFFICE
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2397
Practice Address - Country:US
Practice Address - Phone:973-642-6500
Practice Address - Fax:973-741-2700
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00260200213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8560005Medicaid
NJ8560005Medicaid
NJU80247Medicare UPIN
NJ045509Medicare ID - Type Unspecified
NJP00002134Medicare ID - Type UnspecifiedRAILROAD MEDICARE