Provider Demographics
NPI:1043283849
Name:BASHA, AHSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:AHSAN
Middle Name:M
Last Name:BASHA
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 1:1490 E WALNUT ST STE A
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1806
Mailing Address - Country:US
Mailing Address - Phone:815-432-0250
Mailing Address - Fax:815-432-5217
Practice Address - Street 1:1490 E WALNUT ST STE A
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1806
Practice Address - Country:US
Practice Address - Phone:815-432-0250
Practice Address - Fax:815-432-5217
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30683207RH0003X
IL036093863207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ71173OtherMEDICARE ID
IL036093863Medicaid
AZ71613601Medicaid