Provider Demographics
NPI:1245389238
Name:FELAHY, BASIL (MD)
Entity Type:Individual
Prefix:DR
First Name:BASIL
Middle Name:
Last Name:FELAHY
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 1:11050 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3068
Mailing Address - Country:US
Mailing Address - Phone:310-635-3800
Mailing Address - Fax:310-635-0364
Practice Address - Street 1:11050 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3068
Practice Address - Country:US
Practice Address - Phone:310-635-3800
Practice Address - Fax:310-635-0364
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA36908OtherMEDICAL LICENSE
CA00A369080Medicaid
CAA36908OtherMEDICAL LICENSE
CA00A369080Medicaid