Healthcare Provider Details

I. General information

NPI: 1710220454
Provider Name (Legal Business Name): HARSIMRAN SINGH BASRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 W HAMMER LN
STOCKTON CA
95209-2839
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-954-3370
  • Fax: 209-473-9298
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA151896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: