Basic Information
| Provider Information | |||||||||
| NPI: | 1942733944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASKONI | ||||||||
| FirstName: | BASHAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.B.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44405 WOODWARD AVE | ||||||||
| Address2: | MEDICAL EDUCATION, H-23 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483586233 | ||||||||
| FaxNumber: | 2488583244 | ||||||||
| Practice Location | |||||||||
| Address1: | 44405 WOODWARD AVE | ||||||||
| Address2: | MEDICAL EDUCATION, H-23 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483586233 | ||||||||
| FaxNumber: | 2488583244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/09/2017 | ||||||||
| NPIReactivationDate: | 12/07/2017 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301112291 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.