Provider Demographics
NPI:1710957733
Name:DEMIAN, BASSEM M (DPM)
Entity Type:Individual
Prefix:DR
First Name:BASSEM
Middle Name:M
Last Name:DEMIAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 HERBERTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-1734
Mailing Address - Country:US
Mailing Address - Phone:732-840-8989
Mailing Address - Fax:
Practice Address - Street 1:292 HERBERTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-1734
Practice Address - Country:US
Practice Address - Phone:732-840-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00215100213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5549604Medicaid
NJ0522230001Medicare NSC
NJ5549604Medicaid