Provider Demographics
NPI:1578564381
Name:BASSETT, BERTRAND (MD)
Entity Type:Individual
Prefix:DR
First Name:BERTRAND
Middle Name:
Last Name:BASSETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OLAN
Other - Middle Name:
Other - Last Name:BASSETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:630 PASEO DEL PUEBLO SUR STE 150
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-7002
Mailing Address - Country:US
Mailing Address - Phone:505-758-3005
Mailing Address - Fax:505-758-1070
Practice Address - Street 1:630 PASEO DEL PUEBLO SUR STE 150
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-7002
Practice Address - Country:US
Practice Address - Phone:505-758-3005
Practice Address - Fax:505-758-1070
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34482831Medicaid
P00390745OtherRAILROAD MEDICARE
WA8400731Medicaid
NM348606902Medicare PIN
P00390745OtherRAILROAD MEDICARE