Provider Demographics
NPI:1023143427
Name:RAYMUNDO S BAUTISTA, MD, PROF CORP
Entity type:Organization
Organization Name:RAYMUNDO S BAUTISTA, MD, PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMUNDO
Authorized Official - Middle Name:SEVILLA
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-914-3871
Mailing Address - Street 1:118 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3364
Mailing Address - Country:US
Mailing Address - Phone:626-914-3871
Mailing Address - Fax:626-963-2816
Practice Address - Street 1:118 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3364
Practice Address - Country:US
Practice Address - Phone:626-914-3871
Practice Address - Fax:626-963-2816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52874207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A528740Medicaid
CAA52874OtherPRES. MEDICAL STATE LIC#
CAA52874Medicare ID - Type UnspecifiedPRES. MCARE ID#
CAA52874OtherPRES. MEDICAL STATE LIC#