Healthcare Provider Details

I. General information

NPI: 1639249352
Provider Name (Legal Business Name): JAVIER BAQUERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 QUEENS BLVD
LONG ISLAND CITY NY
11101-1725
US

IV. Provider business mailing address

64 BRIDGE RD
MANHASSET NY
11030-1544
US

V. Phone/Fax

Practice location:
  • Phone: 718-361-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number103619
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: