Provider Demographics
NPI:1609091909
Name:BAEZ, JULISSA (MD)
Entity type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:BAEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-5408
Mailing Address - Country:US
Mailing Address - Phone:347-275-2030
Mailing Address - Fax:347-275-2030
Practice Address - Street 1:232 E 12TH ST
Practice Address - Street 2:UNIT 1G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9151
Practice Address - Country:US
Practice Address - Phone:646-524-6351
Practice Address - Fax:646-524-6362
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2329012080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02797648Medicaid