Provider Demographics
NPI:1942286703
Name:BASTA, JAMES W (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:BASTA
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 1:1960 NE 47TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7708
Mailing Address - Country:US
Mailing Address - Phone:954-493-5005
Mailing Address - Fax:954-938-0957
Practice Address - Street 1:1960 NE 47TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7708
Practice Address - Country:US
Practice Address - Phone:954-493-5005
Practice Address - Fax:954-938-0957
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0023287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79173OtherBLUE CROSS BLUE SHIELD
FL79173OtherBLUE CROSS BLUE SHIELD
FL79173ZMedicare ID - Type Unspecified