MEDICARE: DANIEL J BASULTO 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	208D00000X	General Practice Physician	ME81034	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962413385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL J BASULTO MD

Provider Business Mailing Address
First Line	:	9208 HARDING AVE
Second Line	:
City	:	SURFSIDE
State	:	FL
Zip	:	33154-3010
Country	:	US
Telephone Number	:	786-252-8261
Fax Number	:	305-861-2785

Provider Business Practice Location Address
First Line	:	4578 W 12TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-3325
Country	:	US
Telephone Number	:	305-828-1989
Fax Number	:	305-558-7397

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

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	10/09/2020

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