Provider Demographics
NPI:1417492281
Name:BASTARDO, CARLOS
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:BASTARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:DEBRA
Other - Middle Name:LYNN
Other - Last Name:BASTARDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11191 SHADYLANE DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8623
Mailing Address - Country:US
Mailing Address - Phone:574-936-4152
Mailing Address - Fax:312-256-9390
Practice Address - Street 1:11191 SHADYLANE DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8623
Practice Address - Country:US
Practice Address - Phone:574-936-4152
Practice Address - Fax:312-256-9390
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3577690405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3577690OtherNATIONAL PRODUCER NUMBER