Provider Demographics
NPI:1154316081
Name:BAUTISTA, PRIMO V (MD)
Entity Type:Individual
Prefix:
First Name:PRIMO
Middle Name:V
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 157
Mailing Address - Street 2:
Mailing Address - City:GRAPEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15634-0157
Mailing Address - Country:US
Mailing Address - Phone:724-527-6517
Mailing Address - Fax:724-527-6519
Practice Address - Street 1:600 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-2505
Practice Address - Country:US
Practice Address - Phone:724-527-3551
Practice Address - Fax:724-527-6519
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019326E207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009369890005Medicaid
PA36621OtherBS
PA36621OtherBS
PA0009369890005Medicaid