Provider Demographics
NPI:1619955192
Name:BAUTISTA, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 HOSPITAL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-4275
Mailing Address - Fax:740-779-4257
Practice Address - Street 1:1000 VETERANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9586
Practice Address - Country:US
Practice Address - Phone:740-395-8090
Practice Address - Fax:740-395-8197
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2004-0547208000000X, 2080P0204X
OH35.089012208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10016535OtherLOVELACE HEALTH/SALUD
P00137209OtherRAILROAD MEDICARE
NMPROVP11655OtherMOLINA
NM201047701OtherPRESBYTERIAN HEALTH/SALUD
OH2711211Medicaid
AZ885808OtherAHCCCS
NM99238071Medicaid
NMNM009R63OtherBC/BS
OH348431707Medicare PIN