Healthcare Provider Details

I. General information

NPI: 1225482706
Provider Name (Legal Business Name): JOSEPH RYAN BAUTISTA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W 24TH ST FL 2
NEW YORK NY
10010-3560
US

IV. Provider business mailing address

30 W 24TH ST FL 2
NEW YORK NY
10010-3560
US

V. Phone/Fax

Practice location:
  • Phone: 212-366-5100
  • Fax:
Mailing address:
  • Phone: 212-366-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number297723
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: