Provider Demographics
NPI:1073522884
Name:BASTA, ONSY SAMY (MD)
Entity Type:Individual
Prefix:DR
First Name:ONSY
Middle Name:SAMY
Last Name:BASTA
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 1:225 W BROADWAY
Mailing Address - Street 2:100
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1331
Mailing Address - Country:US
Mailing Address - Phone:818-545-7770
Mailing Address - Fax:
Practice Address - Street 1:225 W BROADWAY
Practice Address - Street 2:100
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1331
Practice Address - Country:US
Practice Address - Phone:818-545-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48938208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG22987Medicare UPIN