Provider Demographics
NPI:1972602191
Name:BASARA, MATTHEW PETER (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PETER
Last Name:BASARA
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 1:5045 ROUTE 130
Mailing Address - Street 2:SUITE E
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-9707
Mailing Address - Country:US
Mailing Address - Phone:856-764-2525
Mailing Address - Fax:856-764-6344
Practice Address - Street 1:5045 ROUTE 130
Practice Address - Street 2:SUITE E
Practice Address - City:DELRAN
Practice Address - State:NJ
Practice Address - Zip Code:08075-9707
Practice Address - Country:US
Practice Address - Phone:856-764-2525
Practice Address - Fax:856-764-6344
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA57034207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
684338NTRMedicare ID - Type Unspecified
E96013Medicare UPIN