1629006903 NPI number — DR. DAN F BAUTISTA M.D.

Table of content: DR. DAN F BAUTISTA M.D. (NPI 1629006903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629006903 NPI number — DR. DAN F BAUTISTA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUTISTA
Provider First Name:
DAN
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1629006903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1840 COMMERCE CENTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRBORN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45324-6337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-754-4580
Provider Business Mailing Address Fax Number:
937-754-4575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 COMMERCE CENTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBORN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45324-6337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-754-4580
Provider Business Practice Location Address Fax Number:
937-754-4575
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35073682B , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300107 . This is a "AMERIGROUP PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: D7368201 . This is a "HUMANA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 310809436DAB . This is a "SUMMIT PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 32004929300 . This is a "BWC PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5405631 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2897281 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2080233 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2871969 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 320049293027 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000259761 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0109918 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P12036623 . This is a "MULTIPLAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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