Provider Demographics
NPI:1285626515
Name:BASOVICH, LEONID (DO, DAOBFP)
Entity Type:Individual
Prefix:DR
First Name:LEONID
Middle Name:
Last Name:BASOVICH
Suffix:
Gender:M
Credentials:DO, DAOBFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 GREENBACK LN STE 103
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-5800
Mailing Address - Country:US
Mailing Address - Phone:916-905-1777
Mailing Address - Fax:888-855-7555
Practice Address - Street 1:7777 GREENBACK LN STE 103
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-5800
Practice Address - Country:US
Practice Address - Phone:916-905-1777
Practice Address - Fax:888-855-7555
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA13731204D00000X, 207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2642PWR601Medicare PIN
NYI36307Medicare UPIN