Provider Demographics
NPI:1821091794
Name:BASTIBLE, DEIRDRE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:
Last Name:BASTIBLE
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 1:20 LOSSON RD
Mailing Address - Street 2:STE 105
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-2379
Mailing Address - Country:US
Mailing Address - Phone:716-558-7727
Mailing Address - Fax:
Practice Address - Street 1:20 LOSSON RD
Practice Address - Street 2:STE 105
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-2379
Practice Address - Country:US
Practice Address - Phone:716-558-7727
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164517207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE44934Medicare UPIN