Provider Demographics
NPI:1831750306
Name:BASTOLA, PRASANNA (MD)
Entity type:Individual
Prefix:DR
First Name:PRASANNA
Middle Name:
Last Name:BASTOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4510
Mailing Address - Country:US
Mailing Address - Phone:951-599-8403
Mailing Address - Fax:951-766-0930
Practice Address - Street 1:1023 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4510
Practice Address - Country:US
Practice Address - Phone:951-599-8403
Practice Address - Fax:951-766-0930
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA177433208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics