Provider Demographics
NPI:1306003033
Name:BASTOLA, SHYAMAL RAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYAMAL
Middle Name:RAJ
Last Name:BASTOLA
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:945 BETHESDA DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-0801
Mailing Address - Country:US
Mailing Address - Phone:740-454-4788
Mailing Address - Fax:740-450-6157
Practice Address - Street 1:1246 ASHLAND AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2861
Practice Address - Country:US
Practice Address - Phone:740-454-5271
Practice Address - Fax:740-455-7588
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2014-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY242899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3153537Medicaid
OH3153537Medicaid