Provider Demographics
NPI:1083619704
Name:BASILE, MYRTHA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MYRTHA
Middle Name:
Last Name:BASILE
Suffix:
Gender:F
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 731912
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1912
Mailing Address - Country:US
Mailing Address - Phone:903-877-7777
Mailing Address - Fax:903-877-7754
Practice Address - Street 1:721 CLINIC DR
Practice Address - Street 2:STE A
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2043
Practice Address - Country:US
Practice Address - Phone:903-592-6152
Practice Address - Fax:903-526-0629
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6778207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J8440OtherBLUE CROSS BLUE SHIELD
TX1618910-01Medicaid
TX8J8440OtherBLUE CROSS BLUE SHIELD
TXE89273Medicare UPIN
TX8A9798Medicare ID - Type Unspecified