Provider Demographics
NPI:1770639080
Name:BAUTISTA, BRIGID B (MD)
Entity Type:Individual
Prefix:
First Name:BRIGID
Middle Name:B
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:561 FAIRTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2412
Mailing Address - Country:US
Mailing Address - Phone:215-487-4164
Mailing Address - Fax:267-338-2272
Practice Address - Street 1:561 FAIRTHORNE AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19128-2412
Practice Address - Country:US
Practice Address - Phone:215-487-4164
Practice Address - Fax:267-338-2272
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072209L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH35047Medicare UPIN