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General NPI Number Information
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NPI Number | 1063620060
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Entity Type | Individual
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Provider Name | BASSAM N ODATALLA M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/19/2015
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Provider Practice Location Address
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Address Line | 200 FAIRFIELD RD
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City | FAIRFIELD
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State | NJ
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Zip | 07004-2426
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Country | US
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Telephone | 973-487-1944
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Fax | 973-487-1945
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Provider Business Mailing Address
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Address Line | 200 FAIRFIELD RD
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City | FAIRFIELD
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State | NJ
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Zip | 07004-2426
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Country | US
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Telephone | 973-487-1944
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Fax | 973-487-1945
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 08610800
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License Number State | NJ
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