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General NPI Number Information
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NPI Number | 1912962028
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Entity Type | Individual
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Provider Name | MICHAEL DAVID BASTASCH MD
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Gender | Male
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 06/23/2021
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Provider Practice Location Address
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Address Line | 39101 CIVIC CENTER DR
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City | FREMONT
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State | CA
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Zip | 94538-5817
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Country | US
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Telephone | 510-796-7212
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Fax | 510-745-6469
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Provider Business Mailing Address
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Address Line | 1801 S PALESTINE ST
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City | ATHENS
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State | TX
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Zip | 75751-5605
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Country | US
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Telephone | 903-677-8300
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Fax | 903-677-8354
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | A85084
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | L9092
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License Number State | TX
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