Provider Demographics
NPI:1295191112
Name:BASSO, DOUGLAS (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BASSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 ENDICOTT CT
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-8210
Mailing Address - Country:US
Mailing Address - Phone:618-578-8667
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD STE C15
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2300
Practice Address - Country:US
Practice Address - Phone:618-578-8667
Practice Address - Fax:314-983-9650
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135.000901213ES0103X
MO2018037270213ES0103X
IL016.005775213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery