=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467654343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOMNATH BASU MD PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2007
-----------------------------------------------------
Last Update Date | 12/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10800 MAGNOLIA AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-319-0421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10153 1/2 RIVERSIDE DR SUITE # 580
-----------------------------------------------------
City | TOLUCA LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91602-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-319-0421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | A97900
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------