Provider Demographics
NPI:1366428559
Name:BASU, HRIDENDRA N (MD)
Entity type:Individual
Prefix:
First Name:HRIDENDRA
Middle Name:N
Last Name:BASU
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 1:146 W DALE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1901
Mailing Address - Country:US
Mailing Address - Phone:319-234-4431
Mailing Address - Fax:319-235-5004
Practice Address - Street 1:146 W DALE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1901
Practice Address - Country:US
Practice Address - Phone:319-234-4431
Practice Address - Fax:319-235-5004
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19212207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1366428559Medicaid
IA0121236Medicaid
IA110115793OtherRR MEDICARE
IA1366428559Medicaid
IA53294Medicare PIN