Provider Demographics
NPI:1124392725
Name:CEDRIC M. BAUTISTA M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CEDRIC M. BAUTISTA M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CEDRIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-353-6200
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-2010
Mailing Address - Country:US
Mailing Address - Phone:760-353-6200
Mailing Address - Fax:760-353-9817
Practice Address - Street 1:1500 S IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4241
Practice Address - Country:US
Practice Address - Phone:760-353-6200
Practice Address - Fax:760-353-9817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37997208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA37997Medicare UPIN