Healthcare Provider Details

I. General information

NPI: 1881621423
Provider Name (Legal Business Name): JACK BASTOW DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PALISADES DR SUITE 250A
ALBANY NY
12205-1443
US

IV. Provider business mailing address

4 PALISADES DR SUITE 250A
ALBANY NY
12205-1443
US

V. Phone/Fax

Practice location:
  • Phone: 518-458-1771
  • Fax: 518-459-7682
Mailing address:
  • Phone: 518-458-1771
  • Fax: 518-459-7682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number003886
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: