Healthcare Provider Details

I. General information

NPI: 1497843544
Provider Name (Legal Business Name): IMTIAZ SIRAJ BASRAI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 E COLORADO BLVD 8TH.FLOOR
PASADENA CA
91101-2044
US

IV. Provider business mailing address

PO BOX 4309
DIAMOND BAR CA
91765-0309
US

V. Phone/Fax

Practice location:
  • Phone: 626-229-3822
  • Fax:
Mailing address:
  • Phone: 626-229-3822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA036962
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA036962
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA036962
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: