Healthcare Provider Details

I. General information

NPI: 1720428808
Provider Name (Legal Business Name): FERNANDO MAYOR BASTO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 PENNSYLVANIA AVE NW FL 9TH
WASHINGTON DC
20037-3201
US

IV. Provider business mailing address

1731 CHURCH ST NW
WASHINGTON DC
20036-1301
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-2710
  • Fax:
Mailing address:
  • Phone: 310-994-5092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberMD049273
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberA138310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: