Provider Demographics
NPI:1629006903
Name:BAUTISTA, DAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:F
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 COMMERCE CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6337
Mailing Address - Country:US
Mailing Address - Phone:937-754-4580
Mailing Address - Fax:937-754-4575
Practice Address - Street 1:1840 COMMERCE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6337
Practice Address - Country:US
Practice Address - Phone:937-754-4580
Practice Address - Fax:937-754-4575
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073682B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH300107OtherAMERIGROUP PIN
OHD7368201OtherHUMANA
OH310809436DABOtherSUMMIT PIN
OH32004929300OtherBWC PIN
OH5405631OtherAETNA
OH2897281OtherCIGNA
OH2080233Medicaid
OH2871969Medicaid
OH320049293027OtherCARESOURCE
OH000000259761OtherBLUE CROSS BLUE SHIELD
OH0109918OtherUNITED HEALTHCARE
OHP12036623OtherMULTIPLAN
OHP00060976Medicare PIN
OH2897281OtherCIGNA
OH2080233Medicaid