Provider Demographics
NPI:1548241979
Name:BASS, FARA DAWN (DPM)
Entity Type:Individual
Prefix:DR
First Name:FARA
Middle Name:DAWN
Last Name:BASS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2381 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5027
Mailing Address - Country:US
Mailing Address - Phone:718-743-1400
Mailing Address - Fax:718-743-7003
Practice Address - Street 1:2381 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5027
Practice Address - Country:US
Practice Address - Phone:718-743-1400
Practice Address - Fax:718-743-7003
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 002518213E00000X
NYNY005164213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P469339OtherOXFORD
NY01578803Medicaid
2030683OtherUNITED HEALTHCARE
6201069OtherGHI
P756130Medicare PIN
P469339OtherOXFORD