Provider Demographics
NPI:1225044035
Name:BAJWA, GURNAM S (MD)
Entity Type:Individual
Prefix:
First Name:GURNAM
Middle Name:S
Last Name:BAJWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206A WILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592
Mailing Address - Country:US
Mailing Address - Phone:434-572-2744
Mailing Address - Fax:434-572-2785
Practice Address - Street 1:2206A WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592
Practice Address - Country:US
Practice Address - Phone:434-572-2744
Practice Address - Fax:434-572-2785
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027276208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007313527Medicaid
VA292847OtherANTHEM BCBS
B09465Medicare UPIN
VA007313527Medicaid