Provider Demographics
NPI:1487072559
Name:BADER, BASSAM
Entity type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:BADER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12223 HIGHLAND AVE STE 106-526
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2574
Mailing Address - Country:US
Mailing Address - Phone:714-676-3880
Mailing Address - Fax:
Practice Address - Street 1:3865 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3919
Practice Address - Country:US
Practice Address - Phone:714-676-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301104969207R00000X, 208M00000X
CAA170093208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine