Provider Demographics
NPI:1295937332
Name:BAST, PETER HENRY (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:HENRY
Last Name:BAST
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 1:111 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4791
Mailing Address - Country:US
Mailing Address - Phone:616-396-0006
Mailing Address - Fax:
Practice Address - Street 1:111 W 24TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4791
Practice Address - Country:US
Practice Address - Phone:616-396-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088667207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1295937332OtherBLUE CROSS / BLUE SHIELD
MI12094092OtherCAQH
1295937332OtherBLUE CROSS / BLUE SHIELD