Provider Demographics
NPI:1528258761
Name:BASAK, ROBERT JAN (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAN
Last Name:BASAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:385 N LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-3610
Mailing Address - Country:US
Mailing Address - Phone:248-628-2597
Mailing Address - Fax:248-628-8802
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2217
Practice Address - Country:US
Practice Address - Phone:248-338-5392
Practice Address - Fax:248-338-5567
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101017311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine