Provider Demographics
NPI:1073566048
Name:BAUTISTA, ELISEO A (MD)
Entity Type:Individual
Prefix:
First Name:ELISEO
Middle Name:A
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 BREMO RD
Mailing Address - Street 2:SUITE 506
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1926
Mailing Address - Country:US
Mailing Address - Phone:804-285-3225
Mailing Address - Fax:804-285-0360
Practice Address - Street 1:5855 BREMO RD
Practice Address - Street 2:SUITE 506
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1926
Practice Address - Country:US
Practice Address - Phone:804-285-3225
Practice Address - Fax:804-285-0360
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051604208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541267736OtherCIGNA
VA30961OtherOPTIMA
VA541267736OtherUNITED HEALTHCARE
VA010024536OtherVA PREMIER
VA541267736OtherCOMMERCIAL
VA002940C63OtherSECURE HORIZONS
VA010024536Medicaid
VA230046OtherSOUTHERN HEALTH
VA44645OtherCARENET
VAC06695OtherGROUP PTAN
VA002940C63OtherHUMANA GOLD
VA269001OtherBC/BS
VA4270015OtherAETNA
VA002940C63OtherOPTIMA MEDICARE
VA30961OtherOPTIMA
VAC01463Medicare Oscar/Certification
VAP00083231Medicare PIN
VA002940C63OtherHUMANA GOLD
VAC06695OtherGROUP PTAN
VA002940C63OtherOPTIMA MEDICARE