Provider Demographics
NPI:1447592845
Name:BASLER, KEITH JOSEPH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JOSEPH
Last Name:BASLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10002 PRINCESS PALM AVE STE 332
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-8327
Mailing Address - Country:US
Mailing Address - Phone:813-571-7184
Mailing Address - Fax:813-654-4695
Practice Address - Street 1:1139 NIKKI VIEW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4879
Practice Address - Country:US
Practice Address - Phone:813-879-8045
Practice Address - Fax:813-685-2477
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-23
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME135348207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program