Provider Demographics
NPI:1407151863
Name:DANIEL J BASULTO MD PA
Entity Type:Organization
Organization Name:DANIEL J BASULTO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BASULTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:786-252-8261
Mailing Address - Street 1:9208 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:FL
Mailing Address - Zip Code:33154-3010
Mailing Address - Country:US
Mailing Address - Phone:786-252-8261
Mailing Address - Fax:305-861-2785
Practice Address - Street 1:4578 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3325
Practice Address - Country:US
Practice Address - Phone:305-828-1989
Practice Address - Fax:305-558-7397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-17
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81034208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH30065Medicare UPIN
FLE4711ZMedicare PIN