Provider Demographics
NPI:1942248083
Name:HANTASH, BASIL M (MD, PHD)
Entity Type:Individual
Prefix:
First Name:BASIL
Middle Name:M
Last Name:HANTASH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 GEER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-1146
Mailing Address - Country:US
Mailing Address - Phone:209-668-3063
Mailing Address - Fax:209-668-4992
Practice Address - Street 1:3800 GEER RD STE 200
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1146
Practice Address - Country:US
Practice Address - Phone:209-668-3063
Practice Address - Fax:209-668-4992
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84839207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A848390OtherMEDI-CAL RENDERING NUMBER
CAZZZP4312ZOtherMEDICARE ID
00A848390OtherMEDICARE PPIN
00A848390OtherMEDICARE PPIN