Healthcare Provider Details

I. General information

NPI: 1659348621
Provider Name (Legal Business Name): STEVEN C BAST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E BONITA AVE STE 101
POMONA CA
91767-1923
US

IV. Provider business mailing address

255 E BONITA AVE STE 101
POMONA CA
91767-1923
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-7437
  • Fax: 909-593-0318
Mailing address:
  • Phone: 909-593-7437
  • Fax: 909-593-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA055098
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA55098
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: