Healthcare Provider Details

I. General information

NPI: 1407151863
Provider Name (Legal Business Name): DANIEL J BASULTO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2011
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9208 HARDING AVE
SURFSIDE FL
33154-3010
US

IV. Provider business mailing address

9208 HARDING AVE
SURFSIDE FL
33154-3010
US

V. Phone/Fax

Practice location:
  • Phone: 786-252-8261
  • Fax:
Mailing address:
  • Phone: 786-252-8261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME81034
License Number StateFL

VIII. Authorized Official

Name: DR. DANIEL J BASULTO
Title or Position: PRESIDENT
Credential:
Phone: 786-252-8261