Healthcare Provider Details

I. General information

NPI: 1790769016
Provider Name (Legal Business Name): MARTIN DAVID BASTUBA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 ALVARADO RD 2208
SAN DIEGO CA
92120-5238
US

IV. Provider business mailing address

6699 ALVARADO RD 2208
SAN DIEGO CA
92120-5238
US

V. Phone/Fax

Practice location:
  • Phone: 619-286-3520
  • Fax: 619-265-1429
Mailing address:
  • Phone: 619-286-3520
  • Fax: 619-265-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG78672
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: