Provider Demographics
NPI:1336266964
Name:BASU, DHIMAN (MD)
Entity Type:Individual
Prefix:
First Name:DHIMAN
Middle Name:
Last Name:BASU
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 1:5009 HERITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5913
Mailing Address - Country:US
Mailing Address - Phone:817-590-0880
Mailing Address - Fax:817-590-0199
Practice Address - Street 1:5009 HERITAGE AVE
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5913
Practice Address - Country:US
Practice Address - Phone:817-590-0880
Practice Address - Fax:817-590-0199
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085466207R00000X, 207RR0500X
390200000X
TXM7849207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191467301Medicaid
TX8K3091Medicare PIN