Provider Demographics
NPI:1720481138
Name:BASIC, IVA
Entity Type:Individual
Prefix:DR
First Name:IVA
Middle Name:
Last Name:BASIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 51ST ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4431
Mailing Address - Country:US
Mailing Address - Phone:718-505-0100
Mailing Address - Fax:
Practice Address - Street 1:4141 51ST ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4431
Practice Address - Country:US
Practice Address - Phone:718-505-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008227152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist