Individual
BASIL D. FOSSUM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
914B MAR WALT DR, 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
(850) 862-8564
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
ME53505
FL
208800000X
Urology Physician
Primary
ME53505
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
07317
BCBS FL
FL
01
—
1193041
WELLCARE
FL
01
—
159401
UNIVERSAL HEALTHCARE
FL
01
—
4266997
AETNA THRU EMERALD COAST HEALTH ALLIANCE
FL
01
—
593-08600
BCBS AL
FL
01
—
P00990540
RAILROAD MEDICARE
FL
Enumeration date
05/24/2006
Last updated
01/05/2026
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