Provider Demographics
NPI:1821008913
Name:BANGASH, ISHTIAQUE A (MD)
Entity Type:Individual
Prefix:
First Name:ISHTIAQUE
Middle Name:A
Last Name:BANGASH
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 1:1111 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-4474
Mailing Address - Country:US
Mailing Address - Phone:559-673-3000
Mailing Address - Fax:559-662-2910
Practice Address - Street 1:1111 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-4474
Practice Address - Country:US
Practice Address - Phone:559-673-3000
Practice Address - Fax:559-662-2910
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50964208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB13493FMedicaid
CAGR0068140Medicaid
H11962Medicare UPIN
CAZZZ01107ZMedicare ID - Type Unspecified