Provider Demographics
NPI:1912978693
Name:BASS, ANDREW CLYDE (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:CLYDE
Last Name:BASS
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:MR
Other - First Name:A
Other - Middle Name:C
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:315 SOUTH SCRIVEN AVE
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064
Mailing Address - Country:US
Mailing Address - Phone:386-362-4822
Mailing Address - Fax:386-364-3534
Practice Address - Street 1:315 SOUTH SCRIVEN AVE
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064
Practice Address - Country:US
Practice Address - Phone:386-362-4822
Practice Address - Fax:386-364-3534
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0017754208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16856OtherBCBS
FL16856Medicare ID - Type Unspecified
FL16856OtherBCBS