Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 11284 | MD |
NPI | 1508190182 |
---|---|
Provider Name | Dr. John Robert Basile |
First Address | Baltimore, MD 21201-1510 |
Second Address | Baltimore, MD 21201-1510 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2009 |
Last Update Date | 29/09/2009 |