Provider Demographics
NPI:1841511441
Name:BASALY, ELMIRA SADEGHI RAZLIGHI (MD)
Entity type:Individual
Prefix:
First Name:ELMIRA
Middle Name:SADEGHI RAZLIGHI
Last Name:BASALY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:805 CENTURY MEDICAL DR OFC
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2100
Mailing Address - Country:US
Mailing Address - Phone:321-268-6111
Mailing Address - Fax:321-268-6360
Practice Address - Street 1:951 N WASHINGTON AVE
Practice Address - Street 2:HOSPITALIST DEPT.
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796
Practice Address - Country:US
Practice Address - Phone:321-268-6111
Practice Address - Fax:321-268-6360
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCLL32557207R00000X
NC2016-01587207R00000X, 208M00000X
GA80718208M00000X
FLME125020208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43058500Medicaid
FL016526300Medicaid