Provider Demographics
NPI:1467647776
Name:BASCO, MICHAEL ANGELO (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANGELO
Last Name:BASCO
Suffix:
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 1:1115 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-3440
Mailing Address - Country:US
Mailing Address - Phone:202-262-3262
Mailing Address - Fax:202-484-0308
Practice Address - Street 1:1115 4TH ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3440
Practice Address - Country:US
Practice Address - Phone:202-262-3262
Practice Address - Fax:202-484-0308
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88898207VG0400X
MDD0072935207VG0400X
DCMD039630207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136435807Medicaid
E20049Medicare UPIN
TX136435807Medicaid