Provider Demographics
NPI:1457441974
Name:FARAG, BASEM R (MD)
Entity Type:Individual
Prefix:DR
First Name:BASEM
Middle Name:R
Last Name:FARAG
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 1:3300 E SOUTH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4588
Mailing Address - Country:US
Mailing Address - Phone:626-524-4132
Mailing Address - Fax:
Practice Address - Street 1:3300 E SOUTH ST STE 201
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90805
Practice Address - Country:US
Practice Address - Phone:626-524-4132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53207207Q00000X
NJMA07030500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine