Provider Demographics
NPI:1366458689
Name:BASTA, MAGDY (MD)
Entity Type:Individual
Prefix:
First Name:MAGDY
Middle Name:
Last Name:BASTA
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 1:1035 US HIGHWAY 46
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2468
Mailing Address - Country:US
Mailing Address - Phone:973-249-9620
Mailing Address - Fax:
Practice Address - Street 1:1035 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2468
Practice Address - Country:US
Practice Address - Phone:973-249-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06184900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6506500Medicaid
NJ19085Medicare ID - Type Unspecified
NJ6506500Medicaid