Provider Demographics
NPI:1730111063
Name:MANEJWALA, FAZAL M (MD)
Entity Type:Individual
Prefix:
First Name:FAZAL
Middle Name:M
Last Name:MANEJWALA
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 1:8110 N BROTHER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2760
Mailing Address - Country:US
Mailing Address - Phone:901-255-5221
Mailing Address - Fax:901-373-4511
Practice Address - Street 1:7900 AIRWAYS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4113
Practice Address - Country:US
Practice Address - Phone:901-454-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD027081207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3090888OtherBCBS
MS00122091Medicaid
TNG70484Medicare PIN
TN3824270Medicare PIN
MS00122091Medicaid