Provider Demographics
NPI:1952070351
Name:BAUTISTA, JUAN M SR
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:BAUTISTA
Suffix:SR
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 1:3063 W CHAPMAN AVE APT 2128
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-1741
Mailing Address - Country:US
Mailing Address - Phone:714-398-3400
Mailing Address - Fax:
Practice Address - Street 1:3063 W CHAPMAN AVE APT 2128
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-1741
Practice Address - Country:US
Practice Address - Phone:714-398-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC6202844172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver