Provider Demographics
NPI:1306856992
Name:BAUTISTA, DAISY IBANEZ (MD)
Entity type:Individual
Prefix:DR
First Name:DAISY
Middle Name:IBANEZ
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:465 SALEM ST APT 104
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2976
Mailing Address - Country:US
Mailing Address - Phone:213-399-4451
Mailing Address - Fax:
Practice Address - Street 1:1930 WILSHIRE BLVD
Practice Address - Street 2:#803
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3605
Practice Address - Country:US
Practice Address - Phone:213-483-3968
Practice Address - Fax:213-483-3495
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA368969208000000X, 208D00000X
CAA36896207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF84330Medicaid
F84330Medicare UPIN
CAOOA368961Medicare ID - Type Unspecified