Provider Demographics
NPI:1265409940
Name:JIWA, FATIMA R (MBCHB)
Entity type:Individual
Prefix:DR
First Name:FATIMA
Middle Name:R
Last Name:JIWA
Suffix:
Gender:F
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3366 OAKDALE AVE N
Mailing Address - Street 2:#501
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2948
Mailing Address - Country:US
Mailing Address - Phone:763-588-0758
Mailing Address - Fax:763-588-8505
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:#501
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-588-0758
Practice Address - Fax:763-588-8505
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43176208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN737667700Medicaid
MN737667700Medicaid