Provider Demographics
NPI:1063750933
Name:AJAZ, BUSHRA (MD)
Entity type:Individual
Prefix:DR
First Name:BUSHRA
Middle Name:
Last Name:AJAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2776 ENTERPRISE RD # 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8316
Mailing Address - Country:US
Mailing Address - Phone:386-774-1223
Mailing Address - Fax:
Practice Address - Street 1:2776 ENTERPRISE RD # 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8316
Practice Address - Country:US
Practice Address - Phone:386-774-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 118747207R00000X
FLTRN16263207R00000X
FLME118747207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016833300Medicaid
FLME118747OtherMEDICAL LICENSE
FL016833300Medicaid