Provider Demographics
NPI:1669740155
Name:BASIS, IOSIF
Entity type:Individual
Prefix:
First Name:IOSIF
Middle Name:
Last Name:BASIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 SHELTER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3872
Mailing Address - Country:US
Mailing Address - Phone:415-672-7395
Mailing Address - Fax:415-821-9883
Practice Address - Street 1:6330 SHELTER CREEK LN
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3872
Practice Address - Country:US
Practice Address - Phone:415-672-7395
Practice Address - Fax:415-821-9883
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADL B6144499343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAPPLICATION 488257OtherMEDI-CAL