Provider Demographics
NPI:1851398309
Name:BASLER, BONNIE N (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:N
Last Name:BASLER
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 1:3411 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-9413
Mailing Address - Country:US
Mailing Address - Phone:662-844-9376
Mailing Address - Fax:662-844-4326
Practice Address - Street 1:3411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-9413
Practice Address - Country:US
Practice Address - Phone:662-844-9376
Practice Address - Fax:662-844-4326
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA104944OtherANTHEM
VA298379OtherSOUTHERN HEALTH
VA420016OtherCOVENTRY HEALTH
VA010028914Medicaid
VA420016OtherCOVENTRY HEALTH
VA003620S28Medicare PIN