=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568328391
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUDOVICO OCTAVIANO BAQUERIZA III PEDIATRIC NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2025
-----------------------------------------------------
Last Update Date | 12/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3415 BAINBRIDGE AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-741-2150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 754 BRONX RIVER RD APT B11
-----------------------------------------------------
City | BRONXVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10708-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-769-2511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 601107
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 383887
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------