Provider Demographics
NPI:1942305107
Name:BASTIEN, MARIA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:BASTIEN
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 1:14 FOX CT
Mailing Address - Street 2:
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036-4807
Mailing Address - Country:US
Mailing Address - Phone:856-518-9578
Mailing Address - Fax:609-518-9579
Practice Address - Street 1:3111 ROUTE 38
Practice Address - Street 2:BLDG 11 PMB 104
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-9754
Practice Address - Country:US
Practice Address - Phone:609-261-5755
Practice Address - Fax:609-261-7199
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07793000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
086513Medicare ID - Type Unspecified