Provider Demographics
NPI:1700623386
Name:BASRAK, MOHAMAD TALAL
Entity type:Individual
Prefix:
First Name:MOHAMAD TALAL
Middle Name:
Last Name:BASRAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 WESTRIDGE GARDENS WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-3368
Mailing Address - Country:US
Mailing Address - Phone:484-921-7650
Mailing Address - Fax:
Practice Address - Street 1:140 NUTT RD
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3906
Practice Address - Country:US
Practice Address - Phone:484-921-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT230445207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine