Provider Demographics
NPI:1255513404
Name:BACALZO, JAN MICHAEL ABERGAS (PT)
Entity type:Individual
Prefix:
First Name:JAN MICHAEL
Middle Name:ABERGAS
Last Name:BACALZO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 33RD ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2329
Mailing Address - Country:US
Mailing Address - Phone:718-707-6970
Mailing Address - Fax:718-732-2864
Practice Address - Street 1:3270 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-2643
Practice Address - Country:US
Practice Address - Phone:718-626-2699
Practice Address - Fax:718-626-0923
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027723-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist