Provider Demographics
NPI:1235127754
Name:BASTIAENS, LEO JAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:JAN
Last Name:BASTIAENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:366 HERITAGE HLS UNIT A
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-4048
Mailing Address - Country:US
Mailing Address - Phone:412-334-3393
Mailing Address - Fax:844-454-5096
Practice Address - Street 1:1620 ROUTE 22 STE 203
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4052
Practice Address - Country:US
Practice Address - Phone:845-278-2500
Practice Address - Fax:844-454-5096
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1711462084P0804X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06049783Medicaid
PA1191678Medicaid
PAE22233Medicare UPIN