Provider Demographics
NPI:1831261015
Name:BASTER, CARLA A (DO)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:A
Last Name:BASTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:A
Other - Last Name:MADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:29 MINNEWAWA DR
Mailing Address - Street 2:
Mailing Address - City:TIMBERLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-1928
Mailing Address - Country:US
Mailing Address - Phone:440-479-1669
Mailing Address - Fax:
Practice Address - Street 1:29 MINNEWAWA DR
Practice Address - Street 2:
Practice Address - City:TIMBERLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-1928
Practice Address - Country:US
Practice Address - Phone:440-479-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH343003592OtherLICENSE
OH0729733Medicaid
OH343003592OtherLICENSE