Provider Demographics
NPI:1669466793
Name:BASHIR, RIYAZ (MD)
Entity Type:Individual
Prefix:DR
First Name:RIYAZ
Middle Name:
Last Name:BASHIR
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:3/208N
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-8484
Mailing Address - Fax:215-707-8484
Practice Address - Street 1:3509 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-8484
Practice Address - Fax:215-707-3946
Is Sole Proprietor?:No
Enumeration Date:2005-09-05
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434567207RC0000X, 207RI0011X, 207RI0011X
OH35081532207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN544625100Medicaid
OH2335208Medicaid
MN060002428Medicare PIN
OHBA4087444Medicare ID - Type Unspecified
OH2335208Medicaid