Provider Demographics
NPI:1093793689
Name:BAUTISTA, MANUEL M (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:M
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:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:960 WINDHAM CT
Practice Address - Street 2:SUITE 1
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5087
Practice Address - Country:US
Practice Address - Phone:330-726-3357
Practice Address - Fax:330-726-1465
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089622207RP1001X, 207RS0012X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2475585Medicaid
OH2475585Medicaid