MEDICARE: BASRI MD DIABETES RELIEF PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1730691171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASRI MD DIABETES RELIEF PC

Provider Business Mailing Address
First Line	:	4441 AUBURN BLVD STE J
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95841-4139
Country	:	US
Telephone Number	:	916-550-1050
Fax Number	:	916-550-1238

Provider Business Practice Location Address
First Line	:	2825 3RD AVE STE 200
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-4066
Country	:	US
Telephone Number	:	916-550-1050
Fax Number	:	916-550-1238

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	DEANE WALLACE
Credential	:
Telephone Number	:	916-571-9041

Provider Enumeration Date	:	10/25/2017
Last Update Date	:	10/25/2017

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