Provider Demographics
NPI:1912962028
Name:BASTASCH, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:BASTASCH
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 1:1801 S PALESTINE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-5605
Mailing Address - Country:US
Mailing Address - Phone:903-677-8300
Mailing Address - Fax:903-677-8354
Practice Address - Street 1:39101 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-5817
Practice Address - Country:US
Practice Address - Phone:510-796-7212
Practice Address - Fax:510-745-6469
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85084174400000X
TXL9092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16796101Medicaid
TX8C5840Medicare ID - Type Unspecified
TX16796101Medicaid