Provider Demographics
NPI:1063639839
Name:BASS, LEON CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:CHARLES
Last Name:BASS
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 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:ROOM 2746
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-2727
Practice Address - Fax:423-431-6715
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251956207R00000X
TN48080207R00000X, 207RC0200X, 207RS0012X, 207RP1001X
GA001195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1063639839Medicaid
VA1063639839Medicaid
TN1528609Medicaid
KY7100389480Medicaid
VAVV6502BMedicare PIN
VAV V6502AMedicare PIN
TN1528609Medicaid
NC1063639839Medicaid