Provider Demographics
NPI:1366644106
Name:LEONID BASOVICH, DO, PC
Entity Type:Organization
Organization Name:LEONID BASOVICH, DO, PC
Other - Org Name:LEONID BASOVICH, DO, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:BASOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-884-2349
Mailing Address - Street 1:4232 SPRING LN
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7089
Mailing Address - Country:US
Mailing Address - Phone:516-884-2349
Mailing Address - Fax:
Practice Address - Street 1:565 ROUTE 25A STE 101
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2600
Practice Address - Country:US
Practice Address - Phone:631-849-4551
Practice Address - Fax:631-849-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235997204D00000X, 207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1366644106OtherNPI
NYWWR601Medicare PIN