Provider Demographics
NPI:1477351690
Name:RESTIVO, JAKE ROLDAN
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ROLDAN
Last Name:RESTIVO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:WEST CHARLTON
Mailing Address - State:NY
Mailing Address - Zip Code:12010-6810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 I ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20052-0011
Practice Address - Country:US
Practice Address - Phone:202-994-2987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program