MEDICARE: DR. LEO JAN BASTIAENS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	171146	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235127754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEO JAN BASTIAENS M.D.

Provider Business Mailing Address
First Line	:	366 HERITAGE HLS UNIT A
Second Line	:
City	:	SOMERS
State	:	NY
Zip	:	10589-4048
Country	:	US
Telephone Number	:	412-334-3393
Fax Number	:	844-454-5096

Provider Business Practice Location Address
First Line	:	1620 ROUTE 22 STE 203
Second Line	:
City	:	BREWSTER
State	:	NY
Zip	:	10509-4052
Country	:	US
Telephone Number	:	845-278-2500
Fax Number	:	844-454-5096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	04/06/2022

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