Provider Demographics
NPI:1841558657
Name:ELBASHIR, ASAAD (STUDENT)
Entity Type:Individual
Prefix:
First Name:ASAAD
Middle Name:
Last Name:ELBASHIR
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL # SC05
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-5700
Mailing Address - Fax:
Practice Address - Street 1:1524 MCHENRY AVE STE 570
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-572-3880
Practice Address - Fax:209-572-3349
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA155240208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841558657Medicaid