Healthcare Provider Details

I. General information

NPI: 1841558657
Provider Name (Legal Business Name): ASAAD ELBASHIR STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE STE 570
MODESTO CA
95350
US

IV. Provider business mailing address

9300 VALLEY CHILDRENS PL # SC05
MADERA CA
93636-8761
US

V. Phone/Fax

Practice location:
  • Phone: 209-572-3880
  • Fax: 209-572-3349
Mailing address:
  • Phone: 559-353-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA155240
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberA155240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: