Provider Demographics
NPI:1053724674
Name:BASTIDAS PLASTIC SURGERY, PC
Entity type:Organization
Organization Name:BASTIDAS PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:A
Authorized Official - Last Name:BASTIDAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-734-6621
Mailing Address - Street 1:5388 ROLLING HILLS RD
Mailing Address - Street 2:
Mailing Address - City:SAYLORSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18353-8054
Mailing Address - Country:US
Mailing Address - Phone:610-442-0992
Mailing Address - Fax:
Practice Address - Street 1:599 BROADWAY
Practice Address - Street 2:UNIT 1A
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1969
Practice Address - Country:US
Practice Address - Phone:610-442-0992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07689900208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty