Provider Demographics
NPI:1346249794
Name:BAEUERLE, JOHANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:
Last Name:BAEUERLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 PIERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-4610
Mailing Address - Country:US
Mailing Address - Phone:845-353-4266
Mailing Address - Fax:
Practice Address - Street 1:326 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1416
Practice Address - Country:US
Practice Address - Phone:845-358-3300
Practice Address - Fax:845-358-3375
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151232207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B14317Medicare UPIN
41D421Medicare ID - Type Unspecified