Healthcare Provider Details

I. General information

NPI: 1396900379
Provider Name (Legal Business Name): MAHDI BASHA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33080 UTICA RD
FRASER MI
48026-2038
US

IV. Provider business mailing address

6601 INKSTER RD
BLOOMFIELD HILLS MI
48301-2823
US

V. Phone/Fax

Practice location:
  • Phone: 586-296-7250
  • Fax: 586-296-7256
Mailing address:
  • Phone: 586-296-7250
  • Fax: 586-296-7256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0.000211
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberOT012221
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number5101016997
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: