Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | LL29238 | SC |
Y | 2080N0001X | Neonatal-Perinatal Doctor | 068983 | GA |
N | 2080N0001X | Neonatal-Perinatal Doctor | 35.094111 | OH |
NPI | 1083704159 |
---|---|
Provider Name | Dr. Monuj Triven Bashambu |
First Address | Augusta, GA 30901-2602 |
Second Address | Augusta, GA 30912-0004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2006 |
Last Update Date | 16/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000785511 | ANTHEM (01) | OH |
0072631 | (05) | OH |
35.094111 | LICENSE (01) | OH |
9105965 | AETNA (01) | OH |