Provider Demographics
NPI:1720063803
Name:BASU, MANJULA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJULA
Middle Name:
Last Name:BASU
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 1:2480 LLEWELLYN AVE
Mailing Address - Street 2:KIMBROUGH AMBULATORY CARE CENTER
Mailing Address - City:FT MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5800
Mailing Address - Country:US
Mailing Address - Phone:301-677-8270
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:KIMBROUGH AMBULATORY CARE CENTER
Practice Address - City:FT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5800
Practice Address - Country:US
Practice Address - Phone:301-677-8270
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025252208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics