Provider Demographics
NPI:1619015690
Name:BASTA, YONG-SON (MD)
Entity Type:Individual
Prefix:
First Name:YONG-SON
Middle Name:
Last Name:BASTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 HICKOK RD
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-3304
Mailing Address - Country:US
Mailing Address - Phone:203-972-3357
Mailing Address - Fax:
Practice Address - Street 1:STAMFORD HOSPITAL, 30 SHELBURNE RD
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06904-9317
Practice Address - Country:US
Practice Address - Phone:203-276-7051
Practice Address - Fax:203-276-7363
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036501208000000X
VI1273208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001365015Medicaid