Provider Demographics
NPI:1588994321
Name:AJAZ, BUSHRA (MSCCC-A)
Entity type:Individual
Prefix:
First Name:BUSHRA
Middle Name:
Last Name:AJAZ
Suffix:
Gender:F
Credentials:MSCCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 S LINDBERGH BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1373
Mailing Address - Country:US
Mailing Address - Phone:314-729-0077
Mailing Address - Fax:314-729-0101
Practice Address - Street 1:3860 S LINDBERGH BLVD STE 108
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1373
Practice Address - Country:US
Practice Address - Phone:314-729-0077
Practice Address - Fax:314-729-0101
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002008810207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002008810OtherLICENSE NUMBER