Provider Demographics
NPI:1073676458
Name:BAUTISTA, MARIA IMELDA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:IMELDA
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1303 HENRY CLAY AVENUE
Mailing Address - Street 2:NEONATAL MEDICAL GROUP
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118
Mailing Address - Country:US
Mailing Address - Phone:504-896-2229
Mailing Address - Fax:504-896-8835
Practice Address - Street 1:1303 HENRY CLAY AVENUE
Practice Address - Street 2:NEONATAL MEDICAL GROUP
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118
Practice Address - Country:US
Practice Address - Phone:504-896-2229
Practice Address - Fax:504-896-8835
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA07109R2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1361852Medicaid
LA1361852Medicaid
D79795Medicare UPIN