Basic Information
| Provider Information | |||||||||
| NPI: | 1972536266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAWA | ||||||||
| FirstName: | NITIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4476 LEGENDARY DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325415347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504247320 | ||||||||
| FaxNumber: | 8505344174 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 SUGAR SAND LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SANTA ROSA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324597483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505344170 | ||||||||
| FaxNumber: | 8505344174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME91017 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 270726800 | 05 | FL | MEDICAID |