Provider Demographics
NPI:1558416602
Name:BATHIJA, JAGDISH (MD)
Entity Type:Individual
Prefix:DR
First Name:JAGDISH
Middle Name:
Last Name:BATHIJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:BATHIJA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:50 GLENBROOK RD APT 9C
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2951
Mailing Address - Country:US
Mailing Address - Phone:203-536-7152
Mailing Address - Fax:203-286-1872
Practice Address - Street 1:31 STRAWBERRY HILL AVE STE 106
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2681
Practice Address - Country:US
Practice Address - Phone:203-536-7152
Practice Address - Fax:203-286-1872
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0237672084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCSP.0030715OtherCT STATE CONTROL SUBSTANCES
CT23767OtherCT MEDICAL PHYSICIANLICENSE
CT23767OtherCT MEDICAL PHYSICIANLICENSE