Provider Demographics
NPI:1134119308
Name:BAUTISTA, JOSE LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
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 1:7281 W MENLO AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93723-9349
Mailing Address - Country:US
Mailing Address - Phone:559-271-7292
Mailing Address - Fax:
Practice Address - Street 1:2570 JENSEN AVE STE 106
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-2269
Practice Address - Country:US
Practice Address - Phone:559-875-3428
Practice Address - Fax:559-875-3434
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA432930207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC260ZOtherMEDICARE PTAN / PALMETTO (BRMC)
CARHM53933FMedicaid
CA553933Medicare ID - Type UnspecifiedRIVERBEND
CADC260ZOtherMEDICARE PTAN / PALMETTO (BRMC)
CARHM53933FMedicaid