Provider Demographics
NPI:1356602486
Name:BASS, JAMIE EUDORA (DO)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:EUDORA
Last Name:BASS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 103204
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0001
Mailing Address - Country:US
Mailing Address - Phone:352-265-0651
Mailing Address - Fax:352-265-0153
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-1402
Practice Address - Country:US
Practice Address - Phone:352-265-0651
Practice Address - Fax:352-265-0153
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.1658207QG0300X
FLOS19438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116598400Medicaid