Organization
BASIL D. FOSSUM, M.D. PA
Active
Other names
Basil D. Fossum, M.D.
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BASIL DUANE FOSSUM MD PA M.D. (OWNER)
(850) 862-2555
Entity
Organization
Contact information
Practice address
914 MAR WALT DR STE B, FORT WALTON BEACH, FL 32547-6706
(850) 226-6572
(850) 862-8564
Mailing address
914 MAR WALT DR STE B, FORT WALTON BEACH, FL 32547-6706
(850) 862-2555
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ME53505
MEDICAL LICENSE
FL
Enumeration date
01/20/2021
Last updated
05/22/2025
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