Provider Demographics
NPI:1205885704
Name:BAZERBASHI, AMMAR (MD)
Entity type:Individual
Prefix:
First Name:AMMAR
Middle Name:
Last Name:BAZERBASHI
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 1:668 N BEERS ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1526
Mailing Address - Country:US
Mailing Address - Phone:732-888-0017
Mailing Address - Fax:732-888-0097
Practice Address - Street 1:668 N BEERS ST
Practice Address - Street 2:SUITE 105
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1526
Practice Address - Country:US
Practice Address - Phone:732-888-0017
Practice Address - Fax:732-888-0097
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA072160173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH33778Medicare UPIN
NJ046586Medicare ID - Type Unspecified