MEDICARE: JOHANNA V BASA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208600000X	Surgery Physician	A136671	CA

General Provider Information

NPI Number	:	1821326380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHANNA V BASA M.D.

Provider Business Mailing Address
First Line	:	840 TOWNE CENTER DR
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-5900
Country	:	US
Telephone Number	:	909-398-1550
Fax Number	:	909-398-1488

Provider Business Practice Location Address
First Line	:	520 E FOOTHILL BLVD STE C
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-1200
Country	:	US
Telephone Number	:	909-398-4835
Fax Number	:	909-398-4925

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2009
Last Update Date	:	09/12/2018

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