Provider Demographics
NPI:1255510103
Name:DAVID S BASTAWROS DPM PA
Entity type:Organization
Organization Name:DAVID S BASTAWROS DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:BASTAWROS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-491-3000
Mailing Address - Street 1:PO BOX 261126
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75026-1126
Mailing Address - Country:US
Mailing Address - Phone:972-491-3000
Mailing Address - Fax:972-491-3001
Practice Address - Street 1:4716 ALLIANCE BLVD
Practice Address - Street 2:STE 300
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5371
Practice Address - Country:US
Practice Address - Phone:469-814-3480
Practice Address - Fax:469-814-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP1100X
TX1459213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDO2358OtherMEDICARE RAILROAD
TX00661NMedicare PIN
TX00661NMedicare UPIN
TX1326170001Medicare NSC