Healthcare Provider Details

I. General information

NPI: 1033045802
Provider Name (Legal Business Name): BASEM SOUD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 AVENUE U
BROOKLYN NY
11223
US

IV. Provider business mailing address

11 WASHINGTON DR APT C
WOODLAND PARK NJ
07424-3114
US

V. Phone/Fax

Practice location:
  • Phone: 718-336-0100
  • Fax: 718-336-0100
Mailing address:
  • Phone: 908-590-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberP141566
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: