Provider Demographics
NPI:1235399130
Name:BASSALY, RENEE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIE
Last Name:BASSALY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 W HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-4055
Mailing Address - Country:US
Mailing Address - Phone:813-467-4265
Mailing Address - Fax:813-467-4267
Practice Address - Street 1:3617 W HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-4055
Practice Address - Country:US
Practice Address - Phone:813-467-4265
Practice Address - Fax:813-467-4267
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10371207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003665900Medicaid
FL003665900Medicaid
FL14F12OtherBLUE CROSS BLUE SHIELD