Provider Demographics
NPI:1023136413
Name:PITA, JESSIE BAUTISTA (MD)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:BAUTISTA
Last Name:PITA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:235 PORT RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1701
Mailing Address - Country:US
Mailing Address - Phone:718-876-1732
Mailing Address - Fax:718-876-3459
Practice Address - Street 1:235 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1701
Practice Address - Country:US
Practice Address - Phone:718-876-1732
Practice Address - Fax:718-876-3459
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189860208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060630000022OtherFIDELIS CARE
NY000155690012OtherAFFINITY
NY01178778OtherAMERIGROUP