Basic Information
Provider Information | |||||||||
NPI: | 1194905984 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BASEMAN | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | G. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2234 COLONIAL BLVD. | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 33907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399317342 | ||||||||
FaxNumber: | 2399317385 | ||||||||
Practice Location | |||||||||
Address1: | 70 NEELY RD | ||||||||
Address2: |   | ||||||||
City: | BREVARD | ||||||||
State: | NC | ||||||||
PostalCode: | 287124267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8288835620 | ||||||||
FaxNumber: | 8288848801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2007 | ||||||||
LastUpdateDate: | 10/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2085R0001X | 01046 | NC | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 7305554 | 01 | NC | CIGNA | OTHER | 166KA | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 9550745 | 01 | NC | AETNA | OTHER | 1168717 | 01 | FL | GATEWAY HEALTH | OTHER | 5917841 | 05 | NC |   | MEDICAID |