Healthcare Provider Details

I. General information

NPI: 1023136413
Provider Name (Legal Business Name): JESSIE BAUTISTA PITA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PORT RICHMOND AVE
STATEN ISLAND NY
10302-1701
US

IV. Provider business mailing address

235 PORT RICHMOND AVE
STATEN ISLAND NY
10302-1701
US

V. Phone/Fax

Practice location:
  • Phone: 718-876-1732
  • Fax: 718-876-3459
Mailing address:
  • Phone: 718-876-1732
  • Fax: 718-876-3459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number189860
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: