Provider Demographics
NPI:1104357995
Name:BASITH, SYEDA SUMARA TARANUM (MD)
Entity type:Individual
Prefix:
First Name:SYEDA SUMARA TARANUM
Middle Name:
Last Name:BASITH
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6050
Mailing Address - Fax:239-343-6883
Practice Address - Street 1:9800 S HEALTHPARK DR STE 110
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-6050
Practice Address - Fax:239-343-6883
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140503207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2C0AXOtherBCBS
FL103415600Medicaid