Provider Demographics
NPI:1255350666
Name:BASTIDAS, RODRIGO (MD)
Entity type:Individual
Prefix:DR
First Name:RODRIGO
Middle Name:
Last Name:BASTIDAS
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 1:7210 OAK RIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-2613
Mailing Address - Country:US
Mailing Address - Phone:865-647-5500
Mailing Address - Fax:865-647-5579
Practice Address - Street 1:7210 OAK RIDGE HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931-2613
Practice Address - Country:US
Practice Address - Phone:865-647-5500
Practice Address - Fax:865-647-5579
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-066566207Q00000X
TNMD62777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083874 2Medicaid
IL036083874OtherSTATE LICENSE
F31202Medicare UPIN