Provider Demographics
NPI:1740268317
Name:JANJUA, M IHTESHAM (MD)
Entity type:Individual
Prefix:
First Name:M IHTESHAM
Middle Name:
Last Name:JANJUA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:
Other - Last Name:IHTESHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:120 E TULPEHOCKEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2030
Mailing Address - Country:US
Mailing Address - Phone:215-438-3047
Mailing Address - Fax:215-438-3042
Practice Address - Street 1:3774 RIDGE PIKE
Practice Address - Street 2:STE 100
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-3169
Practice Address - Country:US
Practice Address - Phone:610-489-3330
Practice Address - Fax:610-489-9390
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062987L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017593790003Medicaid
PA0017593790003Medicaid
H04667Medicare UPIN