Provider Demographics
NPI:1407804958
Name:DUDAR, BASIL MOHAMMED (MD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:MOHAMMED
Last Name:DUDAR
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 1:24211 LITTLE MACK AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1190
Mailing Address - Country:US
Mailing Address - Phone:586-498-0440
Mailing Address - Fax:586-498-0401
Practice Address - Street 1:24211 LITTLE MACK AVE
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1190
Practice Address - Country:US
Practice Address - Phone:586-498-0440
Practice Address - Fax:586-498-0401
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079856207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10Other10
MI4856330Medicaid
MI10Other10
MIPENDINGMedicare UPIN