MEDICARE: DR. MARTIN DAVID BASTUBA 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
1	208800000X	Urology Physician	G78672	CA

General Provider Information

NPI Number	:	1790769016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTIN DAVID BASTUBA M.D.

Provider Business Mailing Address
First Line	:	6699 ALVARADO RD
Second Line	:	2208
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5238
Country	:	US
Telephone Number	:	619-286-3520
Fax Number	:	619-265-1429

Provider Business Practice Location Address
First Line	:	6699 ALVARADO RD
Second Line	:	2208
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5238
Country	:	US
Telephone Number	:	619-286-3520
Fax Number	:	619-265-1429

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	08/06/2009

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