Provider Demographics
NPI:1992807705
Name:BASTIDAS, JAIME A (MD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:A
Last Name:BASTIDAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:244 ROSEBERRY ST.
Mailing Address - Street 2:SUITE #5
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865
Mailing Address - Country:US
Mailing Address - Phone:908-454-1704
Mailing Address - Fax:908-454-1706
Practice Address - Street 1:244 ROSEBERRY ST.
Practice Address - Street 2:SUITE #5
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865
Practice Address - Country:US
Practice Address - Phone:908-454-1704
Practice Address - Fax:908-454-1706
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD422370174400000X, 2086S0122X
NJ25MA07689900174400000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ074448ZH1EOtherMEDICARE PTAN
NJ074448UK1OtherMEDICARE PTAN
PA073750OtherMEDICARE PTAN
PA073750OtherMEDICARE PTAN