Provider Demographics
NPI:1487634317
Name:BAUTISTA MEDICAL GROUP
Entity Type:Organization
Organization Name:BAUTISTA MEDICAL GROUP
Other - Org Name:BAUTISTA RESEARCH MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-445-0391
Mailing Address - Street 1:2505 MERCED ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1811
Mailing Address - Country:US
Mailing Address - Phone:559-445-0391
Mailing Address - Fax:559-445-0316
Practice Address - Street 1:2505 MERCED ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1811
Practice Address - Country:US
Practice Address - Phone:559-445-0391
Practice Address - Fax:559-445-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CAA43293207R00000X
CAA84959208000000X
CAA97270208D00000X
CAPA16817363A00000X
CAPA13143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ3862ZOtherBLUE SHIELD
CAGR0063040OtherMEDI-CAL
CAZZZ38362ZMedicare ID - Type UnspecifiedPROVIDER NUMBER
CAGR0063040OtherMEDI-CAL
CAQ30615Medicare UPIN