Provider Demographics
NPI:1053396572
Name:BASU, PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:
Last Name:BASU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9534 WICKHAM WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5524
Mailing Address - Country:US
Mailing Address - Phone:917-226-0284
Mailing Address - Fax:
Practice Address - Street 1:6735 CONROY RD STE 223
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-3570
Practice Address - Country:US
Practice Address - Phone:407-203-2377
Practice Address - Fax:407-203-8811
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51337207RG0100X
NY190318207RG0100X, 207RI0008X
FLME135670207RT0003X, 207RG0100X, 207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant HepatologyGroup - Multi-Specialty
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
166115OtherELDERPLAN
218509OtherWELLCARE
2499388OtherGHI PPO
NY5044440OtherAETNA
HEALTH NETOther4C2929
693723OtherFIRST HEALTH
76220OtherGHI HMO
190318A33OtherHEALTH FIRST
NY60H103OtherBCBS
111517OtherVYTRA
1424916OtherUNITED HEALTH CARE
P627420OtherOXFORD HP
NY09659POtherHIP OF NY
218509OtherWELLCARE
NY60H103OtherBCBS
NY02204Medicare PIN