Provider Demographics
NPI:1164414660
Name:BAUTISTA, ROGELIO L (MD)
Entity Type:Individual
Prefix:
First Name:ROGELIO
Middle Name:L
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 1:1201 N RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-2020
Mailing Address - Country:US
Mailing Address - Phone:660-385-8900
Mailing Address - Fax:660-385-8708
Practice Address - Street 1:1201 N RUTHERFORD ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2020
Practice Address - Country:US
Practice Address - Phone:660-385-8900
Practice Address - Fax:660-385-8708
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO33051208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200148807Medicaid
MO20245OtherANTHEM BCBS
MO022155151OtherTRAVELERS RR MEDICARE
MO000003516Medicare ID - Type Unspecified
MO022155151OtherTRAVELERS RR MEDICARE