Provider Demographics
NPI:1063633188
Name:BAST, BRIAN ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ALAN
Last Name:BAST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:761 MAIN AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-845-2200
Mailing Address - Fax:203-847-1940
Practice Address - Street 1:761 MAIN AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1080
Practice Address - Country:US
Practice Address - Phone:203-845-2200
Practice Address - Fax:203-847-1940
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233705208100000X
CT045336208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00521Medicare PIN