Basic Information
| Provider Information | |||||||||
| NPI: | 1255994901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANICKAVEETTIL MOHAMED BASHEER | ||||||||
| FirstName: | AMJAD | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | UCONN GRADUATE MEDICAL EDUCATION | ||||||||
| Address2: | 263 FARMINGTON AVENUE LM068 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060301921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608794763 | ||||||||
| FaxNumber: | 8608794624 | ||||||||
| Practice Location | |||||||||
| Address1: | UCONN HEALTH - GENERAL MEDICINE CLINIC | ||||||||
| Address2: | 263 FARMINGTON AVE, OP 2 EAST | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060308021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794477 | ||||||||
| FaxNumber: | 8606791025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2019 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.