Provider Demographics
NPI:1497843544
Name:BASRAI, IMTIAZ SIRAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:IMTIAZ
Middle Name:SIRAJ
Last Name:BASRAI
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:PO BOX 4309
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-0309
Mailing Address - Country:US
Mailing Address - Phone:626-229-3822
Mailing Address - Fax:
Practice Address - Street 1:532 E COLORADO BLVD
Practice Address - Street 2:8TH.FLOOR
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2044
Practice Address - Country:US
Practice Address - Phone:626-229-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0369622084P0800X, 2084P0804X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry