Provider Demographics
NPI:1336101880
Name:HUMBERTO BASTO MD PA
Entity Type:Organization
Organization Name:HUMBERTO BASTO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HUMBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:305-940-0068
Mailing Address - Street 1:2300 NE 215 STREET
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180
Mailing Address - Country:US
Mailing Address - Phone:305-940-0068
Mailing Address - Fax:305-932-3940
Practice Address - Street 1:21097 NE 27TH CT
Practice Address - Street 2:SUITE 210
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1204
Practice Address - Country:US
Practice Address - Phone:305-940-0068
Practice Address - Fax:305-932-3940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0036969208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041369100Medicaid
FL96739Medicare PIN
D63975Medicare UPIN