Provider Demographics
NPI:1629101340
Name:BAUTISTA MEDICAL GROUP SOUTHERN CALIFORNIA, INC.
Entity Type:Organization
Organization Name:BAUTISTA MEDICAL GROUP SOUTHERN CALIFORNIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNIST
Authorized Official - Prefix:DR
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:805-524-2559
Mailing Address - Street 1:427 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-1329
Mailing Address - Country:US
Mailing Address - Phone:805-524-2559
Mailing Address - Fax:805-524-2596
Practice Address - Street 1:427 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015
Practice Address - Country:US
Practice Address - Phone:805-524-0777
Practice Address - Fax:805-524-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43293207Q00000X
CAPA15385207Q00000X
CAA97270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063042Medicaid
CAGR0063042Medicaid
CAW15724Medicare ID - Type Unspecified