Provider Demographics
NPI:1689691537
Name:DAISY I .BAUTISTA, MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DAISY I .BAUTISTA, MD, A MEDICAL CORPORATION
Other - Org Name:HOLY MARY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:IBANEZ
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-3968
Mailing Address - Street 1:1930 WILSHIRE BLVD
Mailing Address - Street 2:STE. 803
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3605
Mailing Address - Country:US
Mailing Address - Phone:213-483-3968
Mailing Address - Fax:213-483-3495
Practice Address - Street 1:1930 WILSHIRE BLVD
Practice Address - Street 2:STE. 803
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3605
Practice Address - Country:US
Practice Address - Phone:213-483-3968
Practice Address - Fax:213-483-3495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36896208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF84330Medicaid
F84330Medicare UPIN
CA00A368961Medicare ID - Type Unspecified