Healthcare Provider Details

I. General information

NPI: 1750657078
Provider Name (Legal Business Name): DINA BASTAWROS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 10/26/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 HIGHLAND OAKS DR STE 100
WINSTON SALEM NC
27103
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-1970
  • Fax: 336-774-8601
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2016-00256
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number2016-00256
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: