Provider Demographics
NPI:1740322023
Name:BASAVARAJ, ASHISH (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:ASHISH
Middle Name:
Last Name:BASAVARAJ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21930 75TH AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20809 UNION TPKE
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-3235
Practice Address - Country:US
Practice Address - Phone:718-479-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023750-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP87820Medicare UPIN
NY57415TMedicare ID - Type Unspecified