Provider Demographics
NPI:1396954178
Name:EJAZ, KANWAL (MD)
Entity type:Individual
Prefix:
First Name:KANWAL
Middle Name:
Last Name:EJAZ
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 1:905 HANSHAW RD STE C
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1549
Mailing Address - Country:US
Mailing Address - Phone:607-277-2170
Mailing Address - Fax:607-277-3232
Practice Address - Street 1:905 HANSHAW RD STE C
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1549
Practice Address - Country:US
Practice Address - Phone:607-277-2170
Practice Address - Fax:607-277-2329
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053070207R00000X
MA208850207R00000X
NY295692-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05378529Medicaid
CO18959326Medicaid