MEDICARE: DR. PRASANNA BASTOLA MD

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	208000000X	Pediatrics Physician	A177433	CA

General Provider Information

NPI Number	:	1831750306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRASANNA BASTOLA MD

Provider Business Mailing Address
First Line	:	1023 E FLORIDA AVE
Second Line	:
City	:	HEMET
State	:	CA
Zip	:	92543-4510
Country	:	US
Telephone Number	:	951-599-8403
Fax Number	:	951-766-0930

Provider Business Practice Location Address
First Line	:	1280 E GIBSON RD
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95776-6315
Country	:	US
Telephone Number	:	530-650-4500
Fax Number	:	530-661-4416

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

Provider Enumeration Date	:	06/25/2019
Last Update Date	:	03/11/2026

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