Provider Demographics
NPI:1578548517
Name:BAJWA, QASIM MUSTAFA (MD)
Entity Type:Individual
Prefix:DR
First Name:QASIM
Middle Name:MUSTAFA
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 1:104 COUNTRY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3812
Mailing Address - Country:US
Mailing Address - Phone:314-550-3494
Mailing Address - Fax:636-230-5732
Practice Address - Street 1:1014 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5044
Practice Address - Country:US
Practice Address - Phone:573-472-9993
Practice Address - Fax:573-472-9997
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1022852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00188577OtherMEDICARE RR W/PALMARIS
MOP00236359OtherMEDICARE RR W/QASIM M. BA
MO207708611Medicaid