Provider Demographics
NPI:1922209063
Name:BAHADUR, SHAKEELA WAZEEN (MD)
Entity Type:Individual
Prefix:
First Name:SHAKEELA
Middle Name:WAZEEN
Last Name:BAHADUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAKEELA
Other - Middle Name:
Other - Last Name:WAZEEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2940 E. BANNER GATEWAY DR. SUITE 450
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-4003
Practice Address - Street 1:2946 E BANNER GATEWAY DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-4683
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202117207R00000X, 390200000X
AZ44418207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1091871Medicaid
AZ616870Medicaid
LA1091871Medicaid
LA4N385DE77Medicare PIN
LA4N385DE91Medicare PIN
AZZ147356Medicare PIN