Provider Demographics
NPI:1255366977
Name:BASUK, PAMELA (MD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:BASUK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 UNION BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8019
Mailing Address - Country:US
Mailing Address - Phone:631-666-2900
Mailing Address - Fax:631-666-2900
Practice Address - Street 1:2011 UNION BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8019
Practice Address - Country:US
Practice Address - Phone:631-666-2900
Practice Address - Fax:631-666-2900
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169602-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY34E701Medicare ID - Type Unspecified