Provider Demographics
NPI:1689960205
Name:BASUNDHRA, SAURABH (MD)
Entity Type:Individual
Prefix:
First Name:SAURABH
Middle Name:
Last Name:BASUNDHRA
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 1:3359 KEMP RD
Mailing Address - Street 2:SUITE 250 B
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2565
Mailing Address - Country:US
Mailing Address - Phone:937-458-4650
Mailing Address - Fax:937-458-4659
Practice Address - Street 1:3359 KEMP RD
Practice Address - Street 2:SUITE 250B
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2565
Practice Address - Country:US
Practice Address - Phone:937-458-4650
Practice Address - Fax:937-458-4659
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35125001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0110986Medicaid
OHH389420Medicare PIN
OHH389421Medicare PIN