Provider Demographics
NPI:1487817854
Name:BASSILA, JEAN CLAUDE (MD)
Entity type:Individual
Prefix:
First Name:JEAN CLAUDE
Middle Name:
Last Name:BASSILA
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 1:1005 NORTHGATE DR # 121
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2500
Mailing Address - Country:US
Mailing Address - Phone:707-527-9510
Mailing Address - Fax:833-941-2589
Practice Address - Street 1:4720 HOEN AVE STE 1
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7867
Practice Address - Country:US
Practice Address - Phone:707-527-9510
Practice Address - Fax:833-941-2589
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22784207R00000X, 207RN0300X
CAA145965207RN0300X
CAA145695207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09481295Medicaid
MS09481295Medicaid