Provider Demographics
NPI:1295879435
Name:BASTO, EDGAR ALAIN
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:ALAIN
Last Name:BASTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 SAN JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1351
Mailing Address - Country:US
Mailing Address - Phone:714-776-6692
Mailing Address - Fax:
Practice Address - Street 1:1741 W ROMNEYA DR STE D
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1805
Practice Address - Country:US
Practice Address - Phone:714-776-6692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6662152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX006662FOtherMEDI-CAL