Provider Demographics
NPI:1609808195
Name:BASTIDAS, JEFFERSON AUGUSTO (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:AUGUSTO
Last Name:BASTIDAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14981 NATIONAL AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2600
Mailing Address - Country:US
Mailing Address - Phone:408-358-4747
Mailing Address - Fax:408-358-4742
Practice Address - Street 1:14981 NATIONAL AVE STE 4
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2600
Practice Address - Country:US
Practice Address - Phone:408-358-4747
Practice Address - Fax:408-358-4742
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77498208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF42004Medicare UPIN