Provider Demographics
NPI:1215021720
Name:BAUTISTA, GRACE SEVILLA (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:SEVILLA
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 WEST CONCORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640
Mailing Address - Country:US
Mailing Address - Phone:323-724-9657
Mailing Address - Fax:
Practice Address - Street 1:675 ARROYO PARKWAY, SUITE 330
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:626-395-5268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA045534207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF18553Medicare UPIN