Provider Demographics
NPI:1548646417
Name:BASIR, MARIAM (DO)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:BASIR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18875 BROOKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-8150
Mailing Address - Country:US
Mailing Address - Phone:262-424-4056
Mailing Address - Fax:
Practice Address - Street 1:320 E 94TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5604
Practice Address - Country:US
Practice Address - Phone:262-424-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281246208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics