Basic Information
| Provider Information | |||||||||
| NPI: | 1659476331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NAWAZ | ||||||||
| FirstName: | SHAJITHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 S SILVER SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637037536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5736514345 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 N SPRING ST | ||||||||
| Address2: | STE. 2 | ||||||||
| City: | PERRYVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637751935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733341100 | ||||||||
| FaxNumber: | 5736514345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 2003031776 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 209043603 | 05 | MO | MEDICAID | 538386 | 01 | MO | VALUE OPTIONS | OTHER | 191269 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER |