Provider Demographics
NPI:1871706879
Name:BASHAM, KEVIN LEO (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEO
Last Name:BASHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:99 PLYMOUTH DR N
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1126
Mailing Address - Country:US
Mailing Address - Phone:516-759-6575
Mailing Address - Fax:516-794-2014
Practice Address - Street 1:51 CHARLES LINDBERGH BLVD STE B
Practice Address - Street 2:
Practice Address - City:UNIONDALE
Practice Address - State:NY
Practice Address - Zip Code:11553-3658
Practice Address - Country:US
Practice Address - Phone:516-794-4646
Practice Address - Fax:516-794-2014
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY201500207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology