1962413385 NPI number — DANIEL J BASULTO MD

Table of content: DANIEL J BASULTO MD (NPI 1962413385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962413385 NPI number — DANIEL J BASULTO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASULTO
Provider First Name:
DANIEL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962413385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9208 HARDING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SURFSIDE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33154-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-252-8261
Provider Business Mailing Address Fax Number:
305-861-2785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4578 W 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33012-3325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-828-1989
Provider Business Practice Location Address Fax Number:
305-558-7397
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  ME81034 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108402900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com