Basic Information
| Provider Information | |||||||||
| NPI: | 1942286703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASTA | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1960 NE 47TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333087708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544935005 | ||||||||
| FaxNumber: | 9549380957 | ||||||||
| Practice Location | |||||||||
| Address1: | 1960 NE 47TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333087708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544935005 | ||||||||
| FaxNumber: | 9549380957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0023287 | FL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 79173 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |