Provider Demographics
NPI:1275617763
Name:BASSIG, MARIZA BUNAGAH (MD)
Entity Type:Individual
Prefix:MISS
First Name:MARIZA
Middle Name:BUNAGAH
Last Name:BASSIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11539 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-7373
Mailing Address - Country:US
Mailing Address - Phone:352-592-8401
Mailing Address - Fax:352-592-8402
Practice Address - Street 1:11539 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613
Practice Address - Country:US
Practice Address - Phone:352-592-8401
Practice Address - Fax:352-592-8402
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076845207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G87762Medicare UPIN
E2143Medicare ID - Type Unspecified