Provider Demographics
NPI:1225021462
Name:BASILIOS, MAGED Z (MD INC)
Entity Type:Individual
Prefix:
First Name:MAGED
Middle Name:Z
Last Name:BASILIOS
Suffix:
Gender:M
Credentials:MD INC
Other - Prefix:
Other - First Name:MAGED
Other - Middle Name:
Other - Last Name:BASILIOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4505 SLAUSON AVE
Mailing Address - Street 2:STE E
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-4942
Mailing Address - Country:US
Mailing Address - Phone:323-771-0080
Mailing Address - Fax:888-544-1559
Practice Address - Street 1:4505 SLAUSON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-4942
Practice Address - Country:US
Practice Address - Phone:323-771-0080
Practice Address - Fax:323-771-0090
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA061990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A619900Medicaid
CAA061990OtherLICENCE
CA00A619900Medicaid
CA00A619900Medicaid