Provider Demographics
NPI:1881621423
Name:BASTOW, JACK (DPM)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BASTOW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 PALISADES DR
Mailing Address - Street 2:SUITE 250A
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1443
Mailing Address - Country:US
Mailing Address - Phone:518-458-1771
Mailing Address - Fax:518-459-7682
Practice Address - Street 1:4 PALISADES DR
Practice Address - Street 2:SUITE 250A
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1443
Practice Address - Country:US
Practice Address - Phone:518-458-1771
Practice Address - Fax:518-459-7682
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY003886213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT51285Medicare UPIN
NY52414BMedicare ID - Type Unspecified