Provider Demographics
NPI:1982663480
Name:BAUTISTA, LUCIEN S (DO)
Entity Type:Individual
Prefix:
First Name:LUCIEN
Middle Name:S
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DO
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 27957
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0957
Mailing Address - Country:US
Mailing Address - Phone:908-835-1910
Mailing Address - Fax:908-835-1924
Practice Address - Street 1:200 STRYKERS RD
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-9488
Practice Address - Country:US
Practice Address - Phone:908-859-6568
Practice Address - Fax:908-859-6697
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB68661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ080176344OtherRAILROAD MEDICARE
H04020Medicare UPIN
NJ080176344OtherRAILROAD MEDICARE