Healthcare Provider Details

I. General information

NPI: 1407993694
Provider Name (Legal Business Name): ELIZABETH LOVE BASSETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 S BASCOM AVE DEPARTMENT OF PEDIATRICS
SAN JOSE CA
95128-2604
US

IV. Provider business mailing address

751 S BASCOM AVE DEPARTMENT OF PEDIATRICS
SAN JOSE CA
95128-2604
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-5445
  • Fax: 408-885-6718
Mailing address:
  • Phone: 408-885-5445
  • Fax: 408-885-6718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA89483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: