Provider Demographics
NPI:1003992017
Name:BAUTISTA, VIDEONA B (MD)
Entity Type:Individual
Prefix:DR
First Name:VIDEONA
Middle Name:B
Last Name:BAUTISTA
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 1:1524 SE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2502
Mailing Address - Country:US
Mailing Address - Phone:954-763-6188
Mailing Address - Fax:954-763-6199
Practice Address - Street 1:1524 SE 3RD AVE.
Practice Address - Street 2:
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2502
Practice Address - Country:US
Practice Address - Phone:954-763-6188
Practice Address - Fax:951-763-6199
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029452207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93675Medicare ID - Type UnspecifiedPROVIDER M/C