Provider Demographics
NPI:1497854483
Name:YASSINE, BASSAM (MD)
Entity type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:YASSINE
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 1:910 E GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-4747
Mailing Address - Country:US
Mailing Address - Phone:626-339-9180
Mailing Address - Fax:626-339-9130
Practice Address - Street 1:1135 S. SUNSET AVE SUITE 301
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-552-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A564830Medicaid
CA00A564830Medicaid
CAA56483Medicare ID - Type Unspecified