Basic Information
| Provider Information | |||||||||
| NPI: | 1881019594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASSAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 RATZER RD STE B7 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074707704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733170155 | ||||||||
| FaxNumber: | 9733170149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB09755400 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 25MB09755400 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.