Provider Demographics
NPI:1396900379
Name:BASHA, MAHDI (DO)
Entity type:Individual
Prefix:DR
First Name:MAHDI
Middle Name:
Last Name:BASHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 INKSTER RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2823
Mailing Address - Country:US
Mailing Address - Phone:586-296-7250
Mailing Address - Fax:586-296-7256
Practice Address - Street 1:33080 UTICA RD
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-2038
Practice Address - Country:US
Practice Address - Phone:586-296-7250
Practice Address - Fax:586-296-7256
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAD0.000211207W00000X
PAOT012221207W00000X
MI5101016997207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05332224Medicaid
LA2117700Medicaid
MIP41880010Medicare PIN
LA2117700Medicaid
LA4P197Medicare PIN
MS05332224Medicaid