Basic Information
| Provider Information | |||||||||
| NPI: | 1487817854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASSILA | ||||||||
| FirstName: | JEAN CLAUDE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 NORTHGATE DR # 121 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949032500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075279510 | ||||||||
| FaxNumber: | 8339412589 | ||||||||
| Practice Location | |||||||||
| Address1: | 4720 HOEN AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954057867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075279510 | ||||||||
| FaxNumber: | 8339412589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2008 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22784 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | A145965 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 22784 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | A145695 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 09481295 | 05 | MS | MEDICAID |