Provider Demographics
NPI:1821121237
Name:BASSIN, ROGER E (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:BASSIN
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 1:1705 BERGLUND LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6231
Mailing Address - Country:US
Mailing Address - Phone:321-255-0025
Mailing Address - Fax:321-255-0027
Practice Address - Street 1:1705 BERGLUND LN
Practice Address - Street 2:SUITE 103
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-6231
Practice Address - Country:US
Practice Address - Phone:321-255-0025
Practice Address - Fax:321-255-0027
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85585207W00000X, 208200000X, 2082S0099X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL51442YOtherPTAN
FL51442YOtherPTAN
FLH20233Medicare UPIN