Provider Demographics
NPI:1033783345
Name:BASTARDO, LEONARDO FABIO (MD)
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:FABIO
Last Name:BASTARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 ORATON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-5230
Mailing Address - Country:US
Mailing Address - Phone:939-439-6479
Mailing Address - Fax:
Practice Address - Street 1:715 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00917-5032
Practice Address - Country:US
Practice Address - Phone:787-758-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program