Provider Demographics
NPI:1225017635
Name:BASTA, NABIL N (MD)
Entity Type:Individual
Prefix:DR
First Name:NABIL
Middle Name:N
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 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:317-275-8000
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-5400
Practice Address - Fax:706-774-5096
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043544207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA299904569AMedicaid
GA5258684002OtherBCBS
GA337958OtherWELLCARE
SCG43544Medicaid
GA10058435OtherAMERIGROUP
GA58-146543-001OtherTRICARE
GA5258684002OtherBCBS
GAH82768Medicare UPIN
WI22BDDQHMedicare PIN