Provider Demographics
NPI:1255994901
Name:PANICKAVEETTIL MOHAMED BASHEER, AMJAD (MBBS)
Entity type:Individual
Prefix:
First Name:AMJAD
Middle Name:
Last Name:PANICKAVEETTIL MOHAMED BASHEER
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UCONN GRADUATE MEDICAL EDUCATION
Mailing Address - Street 2:263 FARMINGTON AVENUE LM068
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-1921
Mailing Address - Country:US
Mailing Address - Phone:860-879-4763
Mailing Address - Fax:860-879-4624
Practice Address - Street 1:4520 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8148
Practice Address - Country:US
Practice Address - Phone:605-977-5000
Practice Address - Fax:605-977-5377
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD17325207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program