Provider Demographics
NPI:1841304367
Name:MANEJWALA, B G (MD)
Entity type:Individual
Prefix:
First Name:B
Middle Name:G
Last Name:MANEJWALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14201 LAUREL PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5203
Mailing Address - Country:US
Mailing Address - Phone:301-490-0616
Mailing Address - Fax:301-490-1193
Practice Address - Street 1:14201 LAUREL PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5203
Practice Address - Country:US
Practice Address - Phone:301-490-0616
Practice Address - Fax:301-490-1193
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD13671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11573Medicaid
MDSC176362Medicare ID - Type Unspecified
MDC61800Medicare UPIN