Provider Demographics
NPI:1750657078
Name:BASTAWROS, DINA (MD)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:BASTAWROS
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:770 HIGHLAND OAKS DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-718-1970
Practice Address - Fax:336-774-8601
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00256207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750657078Medicaid
SCNC2769Medicaid
NC1750657078Medicaid