Provider Demographics
NPI:1720495328
Name:M,BASTAWROS,PHYSICIAN,P.C.
Entity Type:Organization
Organization Name:M,BASTAWROS,PHYSICIAN,P.C.
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BASTAWROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-668-3417
Mailing Address - Street 1:314 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2246
Mailing Address - Country:US
Mailing Address - Phone:718-668-3417
Mailing Address - Fax:718-668-3420
Practice Address - Street 1:314 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-2246
Practice Address - Country:US
Practice Address - Phone:718-668-3417
Practice Address - Fax:718-668-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126414302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00597044Medicaid