Provider Demographics
NPI:1033722384
Name:BASTIDA, OSVALDO
Entity Type:Individual
Prefix:
First Name:OSVALDO
Middle Name:
Last Name:BASTIDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 THE CITY DRIVE SOUTH
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3205
Mailing Address - Country:US
Mailing Address - Phone:714-935-6363
Mailing Address - Fax:714-935-8112
Practice Address - Street 1:301 THE CITY DRIVE SOUTH
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3205
Practice Address - Country:US
Practice Address - Phone:714-935-6363
Practice Address - Fax:714-935-8112
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program