Provider Demographics
NPI:1033301080
Name:BASTIDAS, JUAN GUILLERMO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:GUILLERMO
Last Name:BASTIDAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:613 23RD ST STE 210
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2868
Practice Address - Country:US
Practice Address - Phone:606-326-9847
Practice Address - Fax:606-324-3418
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201742208600000X
CAA115149208G00000X
KY49423208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0193538Medicaid
KY7100454120Medicaid
KYK222970Medicare PIN