1417219692 NPI number — MRS. SHAZIA I BASIR QUDDUSI

Table of content: MRS. SHAZIA I BASIR QUDDUSI (NPI 1417219692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417219692 NPI number — MRS. SHAZIA I BASIR QUDDUSI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASIR QUDDUSI
Provider First Name:
SHAZIA
Provider Middle Name:
I
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417219692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 PRIMROSE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HICKSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11801-1617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-218-5439
Provider Business Mailing Address Fax Number:
718-228-4434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9777 QUEENS BLVD
Provider Second Line Business Practice Location Address:
PH
Provider Business Practice Location Address City Name:
REGO PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11374-3335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-218-5439
Provider Business Practice Location Address Fax Number:
718-228-4434
Provider Enumeration Date:
06/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16472 . This is a "SERVICE COORDINATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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