Provider Demographics
NPI:1770818536
Name:BASELLE, ZACHARY J (DO)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:J
Last Name:BASELLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:ZACK
Other - Middle Name:JOHN
Other - Last Name:BASELLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:812 PYRENEES DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1319
Mailing Address - Country:US
Mailing Address - Phone:810-599-5772
Mailing Address - Fax:
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7738
Practice Address - Country:US
Practice Address - Phone:972-519-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA90248207P00000X
MI5101018406207P00000X
CA19564207P00000X
TXQ0220207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01408587OtherRAILROAD
TX336975301Medicaid
TX353548YKN5Medicare PIN