Healthcare Provider Details

I. General information

NPI: 1356114334
Provider Name (Legal Business Name): BASS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E HACIENDA AVE STE C
CAMPBELL CA
95008-6625
US

IV. Provider business mailing address

2637 SHADELANDS DR
WALNUT CREEK CA
94598-2512
US

V. Phone/Fax

Practice location:
  • Phone: 408-404-4700
  • Fax:
Mailing address:
  • Phone: 925-378-4512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: INEZ C WONDEH
Title or Position: CEO
Credential:
Phone: 925-378-0363