Provider Demographics
NPI:1114078995
Name:BAUTISTA, MARCIANO DAVID (DO)
Entity Type:Individual
Prefix:
First Name:MARCIANO
Middle Name:DAVID
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DO
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 5
Mailing Address - Street 2:MILE 187.5 GLENN HWY
Mailing Address - City:GLENNALLEN
Mailing Address - State:AK
Mailing Address - Zip Code:99588-0589
Mailing Address - Country:US
Mailing Address - Phone:907-822-3203
Mailing Address - Fax:
Practice Address - Street 1:MILE 187.5 GLENN HWY
Practice Address - Street 2:
Practice Address - City:GLENNALLEN
Practice Address - State:AK
Practice Address - Zip Code:99588-0589
Practice Address - Country:US
Practice Address - Phone:907-822-3203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35579207Q00000X
AK4535207Q00000X
MI5101013320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKP00673381OtherMEDICARE RAILROAD PTAN
AK1114078995OtherNPI
AKK162088Medicare PIN
AK1114078995OtherNPI