Healthcare Provider Details

I. General information

NPI: 1811937048
Provider Name (Legal Business Name): MILO BASTIANELLI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13660 S JOG RD STE 3
DELRAY BEACH FL
33446-3806
US

IV. Provider business mailing address

13660 S JOG RD STE 3
DELRAY BEACH FL
33446-3806
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-2002
  • Fax: 561-733-3742
Mailing address:
  • Phone: 561-495-2002
  • Fax: 561-733-3742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number25MB06532600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberOS16264
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MB06532600
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number25MB06532600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: