Organization
BASIL FOSSUM MD PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER LORD (OFFICE MANAGER)
(850) 862-2555
Entity
Organization
Contact information
Practice address
914B MAR WALT DR, FORT WALTON BEACH, FL 32547-6706
(850) 862-2555
(850) 862-8564
Mailing address
914B MAR WALT DR, FORT WALTON BEACH, FL 32547-6706
(850) 862-2555
(850) 862-8564
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
—
—
Other
Enumeration date
11/07/2025
Last updated
04/20/2026
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