Provider Demographics
NPI:1679549737
Name:BASSUK, ALEXANDER GABRIEL (MD PHD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:GABRIEL
Last Name:BASSUK
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-1851
Mailing Address - Fax:319-356-4855
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-1851
Practice Address - Fax:319-356-4855
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD36106050208000000X
IA373862084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106050Medicaid
IA70050OtherWELLMARK BCBS
IL036106050Medicaid
IA70050OtherWELLMARK BCBS
I16498Medicare UPIN
ILK10084Medicare ID - Type Unspecified