Provider Demographics
NPI:1942238084
Name:BARODAWALA, FAYYAZ (MD)
Entity Type:Individual
Prefix:
First Name:FAYYAZ
Middle Name:
Last Name:BARODAWALA
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 1:770 PINE ST STE 290
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7516
Mailing Address - Country:US
Mailing Address - Phone:478-743-1458
Mailing Address - Fax:
Practice Address - Street 1:770 PINE ST STE 290
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7516
Practice Address - Country:US
Practice Address - Phone:478-743-1458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA687552085R0202X, 2085R0204X
NY2418982085R0204X, 2085R0202X
NH120502085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10080237OtherSENTARA HEALTH
VA1942238084Medicaid
VA1942238084OtherVIRGINIA PREMIER HEALTH PLAN
VA139178OtherBCBS OF VA
VA10080237OtherOPTIMA HEALTH
VAP00962267OtherRAILROAD MEDICARE
NC5918165Medicaid
PA1010989340001Medicaid
VA139178OtherBCBS OF VA
VAP00962267OtherRAILROAD MEDICARE
PA1010989340001Medicaid