Healthcare Provider Details

I. General information

NPI: 1588619043
Provider Name (Legal Business Name): HOLLY M BASTIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY M BASTIAN FRANCIS MD

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ARISTA DR STE 105
ROCKWALL TX
75032-6860
US

IV. Provider business mailing address

1201 ARISTA DR STE 105
ROCKWALL TX
75032-6860
US

V. Phone/Fax

Practice location:
  • Phone: 972-664-0644
  • Fax: 972-664-0301
Mailing address:
  • Phone: 972-664-0644
  • Fax: 972-664-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01083639A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number17322
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number0001699
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberQ9950
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: