Provider Demographics
NPI:1780660415
Name:BAUTISTA, ANGELINA A (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELINA
Middle Name:A
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:PO BOX 29220
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-0220
Mailing Address - Country:US
Mailing Address - Phone:440-743-4356
Mailing Address - Fax:
Practice Address - Street 1:7007 POWERS BLVD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5437
Practice Address - Country:US
Practice Address - Phone:440-743-4356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045794B174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0490946Medicaid
OHBA0776991Medicare ID - Type Unspecified
OH0490946Medicaid