Basic Information
| Provider Information | |||||||||
| NPI: | 1578827044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAWAD | ||||||||
| FirstName: | HAMZA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 GANNETT DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041063266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074827800 | ||||||||
| FaxNumber: | 2074827898 | ||||||||
| Practice Location | |||||||||
| Address1: | 489 STATE ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079737000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2012 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2017010649 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD21884 | ME | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1578827044 | 05 | ME | MEDICAID | 1578827044 | 05 | MO | MEDICAID | ENROLLED | 05 | IL | MEDICAID |