Provider Demographics
NPI:1710299821
Name:BASTIAN, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24785 STEWART ST STE 204
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1721
Mailing Address - Country:US
Mailing Address - Phone:909-558-4594
Mailing Address - Fax:
Practice Address - Street 1:24785 STEWART ST STE 204
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1721
Practice Address - Country:US
Practice Address - Phone:909-558-4594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA147445208D00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice