Provider Demographics
NPI:1851580708
Name:JAMAL, BASIM
Entity Type:Individual
Prefix:DR
First Name:BASIM
Middle Name:
Last Name:JAMAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 9TH ST APT 707
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5167
Mailing Address - Country:US
Mailing Address - Phone:267-243-5712
Mailing Address - Fax:
Practice Address - Street 1:820 HARRISON AVE, FGH BUILDING 4TH FLOOR
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-7933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL11067204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery