Provider Demographics
NPI:1629022462
Name:BASILE, JOHN CARL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CARL
Last Name:BASILE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COLUMBIA DR
Mailing Address - Street 2:SUITE A327
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3508
Mailing Address - Country:US
Mailing Address - Phone:813-844-4396
Mailing Address - Fax:813-844-4972
Practice Address - Street 1:2 COLUMBIA DR
Practice Address - Street 2:SUITE A327
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3508
Practice Address - Country:US
Practice Address - Phone:813-844-4396
Practice Address - Fax:813-844-4972
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87410207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78807OtherBCBS
FLP00236823OtherMEDICARE RAILROAD
FLP00236823OtherMEDICARE RAILROAD
FL78807Medicare ID - Type Unspecified
FL78807OtherBCBS