Provider Demographics
NPI:1427383850
Name:JAWAID, BUSHRA (MD)
Entity Type:Individual
Prefix:
First Name:BUSHRA
Middle Name:
Last Name:JAWAID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3661 COUNTRY CLUB TER
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-6064
Mailing Address - Country:US
Mailing Address - Phone:650-787-4617
Mailing Address - Fax:
Practice Address - Street 1:200 COTTAGE AVE STE 103
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4935
Practice Address - Country:US
Practice Address - Phone:209-624-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA107456261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program