Provider Demographics
NPI:1619943024
Name:BAUTISTA-AZORES, RICHELLE PILI (MD)
Entity Type:Individual
Prefix:
First Name:RICHELLE
Middle Name:PILI
Last Name:BAUTISTA-AZORES
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 1:1081 N CHINA LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3130
Mailing Address - Country:US
Mailing Address - Phone:760-499-3899
Mailing Address - Fax:760-499-3933
Practice Address - Street 1:1111 N CHINA LAKE BLVD STE 501
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555
Practice Address - Country:US
Practice Address - Phone:760-499-3846
Practice Address - Fax:760-499-3832
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041126208000000X
NDPT 12429208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17047Medicaid
WA1117852Medicaid