Provider Demographics
NPI:1336123181
Name:BASSEY, EDET OKON (MD)
Entity Type:Individual
Prefix:
First Name:EDET
Middle Name:OKON
Last Name:BASSEY
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 1:1041 TALBOTTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8745
Mailing Address - Country:US
Mailing Address - Phone:706-660-8825
Mailing Address - Fax:706-660-8897
Practice Address - Street 1:1041 TALBOTTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8745
Practice Address - Country:US
Practice Address - Phone:706-660-8825
Practice Address - Fax:706-660-8897
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00807881CMedicaid
GA11BDTXWMedicare ID - Type Unspecified
G81322Medicare UPIN