Basic Information
| Provider Information | |||||||||
| NPI: | 1033783345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASTARDO | ||||||||
| FirstName: | LEONARDO | ||||||||
| MiddleName: | FABIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 146 ORATON ST APT 2 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071045230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9394396479 | ||||||||
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| Practice Location | |||||||||
| Address1: | 715 AVE PONCE DE LEON | ||||||||
| Address2: | |||||||||
| City: | HATO REY | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009175032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2021 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | PR | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.