Provider Demographics
NPI:1831393800
Name:ALONSO-BASANTA, MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ALONSO-BASANTA
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 1:3400 CIVIC CENTER BLVD.
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-615-3782
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD.
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-615-3782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4344142085R0001X
NY2330752085R0001X
NJ25MA084703002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology