Provider Demographics
NPI:1962718551
Name:AKSAMAWATI DIT ARJA, WAJIH (MD)
Entity type:Individual
Prefix:
First Name:WAJIH
Middle Name:
Last Name:AKSAMAWATI DIT ARJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CORNELIA ST STE 307
Mailing Address - Street 2:CVPH MEDICAL CENTER - PULMONARY CLINIC
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2779
Mailing Address - Country:US
Mailing Address - Phone:518-562-7705
Mailing Address - Fax:518-562-7706
Practice Address - Street 1:206 CORNELIA ST STE 307
Practice Address - Street 2:CVPH MEDICAL CENTER - PULMONARY CLINIC
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2779
Practice Address - Country:US
Practice Address - Phone:518-562-7705
Practice Address - Fax:518-562-7706
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY275140207RP1001X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03921666Medicaid
NYJ400015467Medicare PIN