MEDICARE: DAPHNE A BASCOM MD, PHD

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
1	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1760314140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAPHNE A BASCOM MD, PHD

Provider Business Mailing Address
First Line	:	1083 WESTYN VIEW CT APT 204
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-5250
Country	:	US
Telephone Number	:	216-536-7836
Fax Number	:

Provider Business Practice Location Address
First Line	:	1083 WESTYN VIEW CT APT 204
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-5250
Country	:	US
Telephone Number	:	216-536-7836
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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