Basic Information
| Provider Information | |||||||||
| NPI: | 1457448342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASIC | ||||||||
| FirstName: | KATHERINA | ||||||||
| MiddleName: | KOBRAEI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918025 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328918025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
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| Practice Location | |||||||||
| Address1: | 51 RAILROAD STREET | ||||||||
| Address2: | DARTMOUTH HITCHCOCK - DERMATOLOGY | ||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033545400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME105569 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | 207R00000X | TRN10017 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207N00000X | 18095 | NH | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 002471100 | 05 | FL | MEDICAID |