Provider Demographics
NPI:1346279460
Name:ABDUL-RAZAK, BASIMA MUHAMMED (MD)
Entity Type:Individual
Prefix:
First Name:BASIMA
Middle Name:MUHAMMED
Last Name:ABDUL-RAZAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RAZAK
Other - Middle Name:
Other - Last Name:MD LLC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:601 E ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:407-975-0412
Mailing Address - Fax:407-975-0413
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-975-0412
Practice Address - Fax:407-975-0413
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53991208000000X
MI4301068389208000000X
FLME134057208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0634484OtherBCBS/BCN PIN NUMBER
146412OtherGREAT LAKES HEALTH PLAN#
16502OtherHEALTH PLAN OF MICHIGAN#
16528OtherMCARE PIN #
7686102OtherAETNA PROVIDER NUMBER
MI4673447-10Medicaid
00000005503AOtherCAPE PIN NUMBER
023862OtherMIDWEST PIN #
MI4331048-10Medicaid