Provider Demographics
NPI:1851655062
Name:BASS, CRYSTAL THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:THERESA
Last Name:BASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:65 W JIMMIE LEEDS RD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NJ
Mailing Address - Zip Code:08240-9102
Mailing Address - Country:US
Mailing Address - Phone:609-404-3817
Mailing Address - Fax:609-404-3818
Practice Address - Street 1:65 W JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240-9102
Practice Address - Country:US
Practice Address - Phone:609-404-3817
Practice Address - Fax:609-404-3818
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA103475002080N0001X
OH35123877208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatrics