Provider Demographics
NPI:1821098088
Name:BASTIAN, BEVAN VERN (MD)
Entity Type:Individual
Prefix:
First Name:BEVAN
Middle Name:VERN
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 1:48 W 1500 N
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-8900
Mailing Address - Country:US
Mailing Address - Phone:435-623-3000
Mailing Address - Fax:
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-623-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187675-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E86404Medicare UPIN
UT007026001Medicare PIN
UT300064515Medicare PIN