Basic Information
| Provider Information | |||||||||
| NPI: | 1053316067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALAJAHI | ||||||||
| FirstName: | FAWAD | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1272 | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716131272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705357457 | ||||||||
| FaxNumber: | 8705352522 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 W 40TH AVE | ||||||||
| Address2: | STE 2B | ||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716036957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705357457 | ||||||||
| FaxNumber: | 8705352522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | R3423 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 55444 | 01 | AR | BCBS | OTHER | 050019322 | 01 | RAILROAD MEDICARE/PGBA | OTHER | 103071001 | 05 | AR | MEDICAID |