Provider Demographics
NPI:1760688394
Name:BASTIDAS, MYRA SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:SUSAN
Last Name:BASTIDAS
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 1:4434 LOS FELIZ BLVD APT 106
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2133
Mailing Address - Country:US
Mailing Address - Phone:323-906-9704
Mailing Address - Fax:
Practice Address - Street 1:4700 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6082
Practice Address - Country:US
Practice Address - Phone:323-783-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99110208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics