Provider Demographics
NPI:1558536979
Name:BASILA, DENNIS JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:JOHN
Last Name:BASILA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23800 JOHN T REID PKWY
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-2841
Mailing Address - Country:US
Mailing Address - Phone:256-999-0808
Mailing Address - Fax:844-490-5876
Practice Address - Street 1:23800 JOHN T REID PKWY
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2841
Practice Address - Country:US
Practice Address - Phone:256-999-0808
Practice Address - Fax:844-490-5876
Is Sole Proprietor?:No
Enumeration Date:2008-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244921-1208000000X
AL36720208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL212646Medicaid
NY03171226Medicaid