Provider Demographics
NPI:1790769016
Name:BASTUBA, MARTIN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:DAVID
Last Name:BASTUBA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6699 ALVARADO RD
Mailing Address - Street 2:2208
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5238
Mailing Address - Country:US
Mailing Address - Phone:619-286-3520
Mailing Address - Fax:619-265-1429
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:2208
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5238
Practice Address - Country:US
Practice Address - Phone:619-286-3520
Practice Address - Fax:619-265-1429
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2009-08-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG78672208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW676872DMedicare ID - Type Unspecified
CAF59601Medicare UPIN