Provider Demographics
NPI:1639112501
Name:BASISTA, MICHAEL PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PAUL
Last Name:BASISTA
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 1:1355 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4221
Mailing Address - Country:US
Mailing Address - Phone:973-778-5566
Mailing Address - Fax:
Practice Address - Street 1:1355 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4221
Practice Address - Country:US
Practice Address - Phone:973-778-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA035109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
594911Medicare PIN
C63188Medicare UPIN