Provider Demographics
NPI:1740746221
Name:BAUTISTA, JOSEPH IAN DAVID
Entity Type:Individual
Prefix:
First Name:JOSEPH IAN
Middle Name:DAVID
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 PAPPAS CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-7034
Mailing Address - Country:US
Mailing Address - Phone:619-764-9588
Mailing Address - Fax:
Practice Address - Street 1:1510 SWEETWATER RD STE B
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-7643
Practice Address - Country:US
Practice Address - Phone:619-552-2870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist