Provider Demographics
NPI:1972536266
Name:BAWA, NITIN (MD)
Entity Type:Individual
Prefix:DR
First Name:NITIN
Middle Name:
Last Name:BAWA
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 1:4476 LEGENDARY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5347
Mailing Address - Country:US
Mailing Address - Phone:850-424-7320
Mailing Address - Fax:850-534-4174
Practice Address - Street 1:4476 LEGENDARY DR STE 100
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5347
Practice Address - Country:US
Practice Address - Phone:850-424-7320
Practice Address - Fax:850-424-7322
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270726800Medicaid
FLI13840Medicare UPIN
FL270726800Medicaid