Provider Demographics
NPI:1346455763
Name:BAUTISTA, ODEZZA AGUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ODEZZA
Middle Name:AGUSTIN
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 1:50 BEECH DR
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19403-5421
Mailing Address - Country:US
Mailing Address - Phone:610-279-6100
Mailing Address - Fax:
Practice Address - Street 1:50 BEECH DR
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19403-5421
Practice Address - Country:US
Practice Address - Phone:610-279-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4329192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry