Provider Demographics
NPI:1659311660
Name:BAUTISTA, IRENE H (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:H
Last Name:BAUTISTA
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 1:18181 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-6949
Mailing Address - Country:US
Mailing Address - Phone:440-816-6414
Mailing Address - Fax:440-816-6421
Practice Address - Street 1:17951 JEFFERSON PARK RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-8439
Practice Address - Country:US
Practice Address - Phone:440-816-6414
Practice Address - Fax:440-816-6421
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048439B208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0507624Medicaid
OH0539518Medicare ID - Type Unspecified
OH0507624Medicaid