Provider Demographics
NPI:1699756999
Name:BASTIANELLI, ITALO MARCELLO (DO)
Entity type:Individual
Prefix:DR
First Name:ITALO
Middle Name:MARCELLO
Last Name:BASTIANELLI
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 MACHINE ST BLDG 2501
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN PROVING GROUND
Mailing Address - State:MD
Mailing Address - Zip Code:21005-5213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:FORT GEORGE G. MEADE MEDDAC
Practice Address - Street 2:2480 LLEWELLYN AVE/SUITE 5800
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5129
Practice Address - Country:US
Practice Address - Phone:410-278-1763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05892100207VX0000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN
NY33025FMedicare ID - Type Unspecified