Healthcare Provider Details

I. General information

NPI: 1912962028
Provider Name (Legal Business Name): MICHAEL DAVID BASTASCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 06/23/2021
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39101 CIVIC CENTER DR
FREMONT CA
94538-5817
US

IV. Provider business mailing address

1801 S PALESTINE ST
ATHENS TX
75751-5605
US

V. Phone/Fax

Practice location:
  • Phone: 510-796-7212
  • Fax: 510-745-6469
Mailing address:
  • Phone: 903-677-8300
  • Fax: 903-677-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA85084
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL9092
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: