Provider Demographics
NPI:1417219692
Name:BASIR QUDDUSI, SHAZIA I
Entity Type:Individual
Prefix:MRS
First Name:SHAZIA
Middle Name:I
Last Name:BASIR QUDDUSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-1617
Mailing Address - Country:US
Mailing Address - Phone:718-218-5439
Mailing Address - Fax:718-228-4434
Practice Address - Street 1:9777 QUEENS BLVD
Practice Address - Street 2:PH
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3335
Practice Address - Country:US
Practice Address - Phone:718-218-5439
Practice Address - Fax:718-228-4434
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16472OtherSERVICE COORDINATION