Provider Demographics
NPI:1245202555
Name:BASILLOTE, JAY B (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:B
Last Name:BASILLOTE
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 1:2071 CLOVE RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1612
Mailing Address - Country:US
Mailing Address - Phone:347-774-8386
Mailing Address - Fax:718-981-4261
Practice Address - Street 1:2071 CLOVE RD
Practice Address - Street 2:SUITE J
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1612
Practice Address - Country:US
Practice Address - Phone:347-774-8386
Practice Address - Fax:718-981-4261
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH89624Medicare UPIN
NY35R251Medicare ID - Type Unspecified