Provider Demographics
NPI:1366531311
Name:BASILE, DOMINICK (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:
Last Name:BASILE
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 1:7 ROSEMARY LN
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4440
Mailing Address - Country:US
Mailing Address - Phone:631-736-3015
Mailing Address - Fax:631-736-9277
Practice Address - Street 1:7 ROSEMARY LN
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-4440
Practice Address - Country:US
Practice Address - Phone:631-736-3015
Practice Address - Fax:631-736-9277
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01038251Medicaid
NYAJ00073OtherMDNY NUMBER
NY96D771OtherFEDERAL BLUE SHIELD
NYBLUE CROSS BLUE SHIEOtherBLUE CROSS BLUE SHIELD
NYCP225OtherOXFORD PROVIDER NUMBER
NY1596OtherVYTRA
NY0096653OtherGHI NUMBER
NY110020159OtherTRAVELERS MEDICARE
NY4211813OtherAETNA
NY6417676OtherCIGNA
NYBLUE CROSS BLUE SHIEOtherBLUE CROSS BLUE SHIELD
NYCP225OtherOXFORD PROVIDER NUMBER