Provider Demographics
NPI:1922182211
Name:BAUTISTA, ALEJANDRO ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEJANDRO
Middle Name:ANTONIO
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81-719 DR. CARREON BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5518
Mailing Address - Country:US
Mailing Address - Phone:760-342-8898
Mailing Address - Fax:760-342-9457
Practice Address - Street 1:81-715 DR. CARREON BLVD
Practice Address - Street 2:STE B1
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5518
Practice Address - Country:US
Practice Address - Phone:760-347-1850
Practice Address - Fax:760-347-8337
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG702332080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF80834Medicare UPIN