Provider Demographics
NPI:1063620060
Name:ODATALLA, BASSAM N (MD)
Entity type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:N
Last Name:ODATALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-2426
Mailing Address - Country:US
Mailing Address - Phone:973-487-1944
Mailing Address - Fax:973-487-1945
Practice Address - Street 1:200 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2426
Practice Address - Country:US
Practice Address - Phone:973-487-1944
Practice Address - Fax:973-487-1945
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ08610800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine