Provider Demographics
NPI:1457328726
Name:BASS, ROBERT T JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:BASS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:570 JACKSONVILLE DR
Practice Address - Street 2:UFJP BEACHES LIVER AND DIGESTIVE
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3813
Practice Address - Country:US
Practice Address - Phone:904-241-8448
Practice Address - Fax:904-244-3425
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63940207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3730948-00Medicaid
GA000553957BMedicaid
FL3730948-00Medicaid
FLE20730Medicare UPIN
GA000553957BMedicaid