Provider Demographics
NPI:1043265549
Name:BAUTISTA, RAYMOND M
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:M
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E 28TH ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2759
Mailing Address - Country:US
Mailing Address - Phone:562-426-2551
Mailing Address - Fax:562-988-0610
Practice Address - Street 1:701 E 28TH ST
Practice Address - Street 2:SUITE 111
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2759
Practice Address - Country:US
Practice Address - Phone:562-426-2551
Practice Address - Fax:562-988-0610
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4157213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine