Provider Demographics
NPI:1679719777
Name:BASU, SUPARNA (MD)
Entity Type:Individual
Prefix:
First Name:SUPARNA
Middle Name:
Last Name:BASU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SAXON WOODS RD
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-7804
Mailing Address - Country:US
Mailing Address - Phone:516-232-5732
Mailing Address - Fax:
Practice Address - Street 1:228 NE JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3802
Practice Address - Country:US
Practice Address - Phone:309-671-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-21
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1474812084P0800X
NYAL4849622 I 95390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry