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NPI Code Detail

MEDICARE: DR. JUAN GUILLERMO BASTIDAS M.D.

MEDICARE: DR. JUAN GUILLERMO BASTIDAS M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208600000XSurgery PhysicianMD.201742LA
2208G00000XThoracic Surgery (Cardiothoracic Vascular Surgery) PhysicianA115149CA
3208G00000XThoracic Surgery (Cardiothoracic Vascular Surgery) Physician49423KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1033301080
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JUAN GUILLERMO BASTIDAS M.D.
Provider Business Mailing Address
First Line : PO BOX 2379
Second Line :
City : ASHLAND
State : KY
Zip : 41105-2379
Country : US
Telephone Number : 606-408-6200
Fax Number : 606-408-6612
Provider Business Practice Location Address
First Line : 613 23RD ST STE 210
Second Line :
City : ASHLAND
State : KY
Zip : 41101-2868
Country : US
Telephone Number : 606-326-9847
Fax Number : 606-324-3418
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/14/2007
Last Update Date : 07/21/2017

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