Provider Demographics
NPI:1376528380
Name:BAUTISTA, ROMAN S (DO)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:S
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 COBBLE CRK
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8638
Mailing Address - Country:US
Mailing Address - Phone:850-776-4265
Mailing Address - Fax:
Practice Address - Street 1:7000 COBBLE CRK
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8638
Practice Address - Country:US
Practice Address - Phone:850-776-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS007158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59067672OtherBSAL
FL265911500Medicaid
FL71 58377OtherAETNA
FL62842OtherBSFL
FL265911500Medicaid
FL62842ZMedicare ID - Type Unspecified