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General NPI Number Information
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NPI Number | 1548898554
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Entity Type | Individual
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Provider Name | MARK BASHA KEROLES MD
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Gender | Male
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Dates
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Enumeration Date | 03/27/2020
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Last Update Date | 06/23/2025
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Provider Practice Location Address
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Address Line | 30051 GRANDPOINT LN
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City | RANCHO PALOS VERDES
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State | CA
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Zip | 90275-6425
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Country | US
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Telephone | 484-351-8459
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Fax |
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Provider Business Mailing Address
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Address Line | 2915 W BITTERS RD STE 201
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City | SAN ANTONIO
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State | TX
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Zip | 78248-2007
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number | A187307
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License Number State | CA
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