Provider Demographics
NPI:1710050380
Name:BASISTA, DAVID WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:BASISTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6940 SANTA TERESA BLVD
Mailing Address - Street 2:#2
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1345
Mailing Address - Country:US
Mailing Address - Phone:408-363-1991
Mailing Address - Fax:408-363-1989
Practice Address - Street 1:6940 SANTA TERESA BLVD
Practice Address - Street 2:#2
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1345
Practice Address - Country:US
Practice Address - Phone:408-363-1991
Practice Address - Fax:408-363-1989
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21229111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0212290Medicare ID - Type UnspecifiedPROVIDER NUMBER