Provider Demographics
NPI:1174699037
Name:BASULTO, DEAN ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:ANTHONY
Last Name:BASULTO
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 1:210 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2901
Mailing Address - Country:US
Mailing Address - Phone:914-682-6532
Mailing Address - Fax:914-681-5260
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:THE ALLEN HOSPITAL, RM 2-095
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:212-932-5218
Practice Address - Fax:914-932-5258
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205919207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY645K21Medicaid
NY645K21Medicare ID - Type Unspecified
NYH35672Medicare UPIN