1780778498 NPI number — JOSE L. BAUTISTA, M.D., INC.

Table of content: (NPI 1780778498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780778498 NPI number — JOSE L. BAUTISTA, M.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSE L. BAUTISTA, M.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780778498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2716 S. ERIN CT.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91789-4638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-665-6704
Provider Business Mailing Address Fax Number:
909-444-7622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 S. SUNSET AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COVINA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-960-6999
Provider Business Practice Location Address Fax Number:
626-337-1231
Provider Enumeration Date:
10/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAUTISTA
Authorized Official First Name:
JOSE
Authorized Official Middle Name:
LUZA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
626-665-6704

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A35250 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A352500 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".