Provider Demographics
NPI:1881616738
Name:BASTAWROS, MARY NABIL (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:NABIL
Last Name:BASTAWROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ANIS
Other - Last Name:BEBAWY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126414208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB19676Medicare UPIN