Healthcare Provider Details

I. General information

NPI: 1083330930
Provider Name (Legal Business Name): BASTION MEDICAL PRACTICE OF FLORIDA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FARMINGTON AVE
FARMINGTON CT
06032-1913
US

IV. Provider business mailing address

400 FARMINGTON AVE
FARMINGTON CT
06032-1913
US

V. Phone/Fax

Practice location:
  • Phone: 786-220-0003
  • Fax:
Mailing address:
  • Phone: 786-220-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VASANTH KAINKARYAM
Title or Position: PRESIDENT
Credential: MD
Phone: 786-220-0003