Provider Demographics
NPI:1972589968
Name:BASTANINEJAD, BIJAN (MD)
Entity Type:Individual
Prefix:
First Name:BIJAN
Middle Name:
Last Name:BASTANINEJAD
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:PO BOX 1308
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-1308
Mailing Address - Country:US
Mailing Address - Phone:573-843-8380
Mailing Address - Fax:573-843-8381
Practice Address - Street 1:2620 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3396
Practice Address - Country:US
Practice Address - Phone:573-785-7721
Practice Address - Fax:573-727-2465
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237324207P00000X
OH35.088489208000000X, 208M00000X
MO2009039681208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI40113OtherHPM
NY02695054Medicaid
OH000000488786OtherANTHEM
MI4920459Medicaid
MI5202199Medicaid
OH7210867OtherAETNA
OH05227OtherPARAMOUNT
OH2678446Medicaid
NY237324OtherBLUECROSS BLUESHIELD
OH000000520832OtherANTHEM
NY02695054Medicaid
OHBA4195762Medicare PIN
MI5202199Medicaid
NY02695054Medicaid