Provider Demographics
NPI:1265405880
Name:BAUTISTA, EDUARDO R (MD)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:R
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DAVIS AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-4488
Mailing Address - Country:US
Mailing Address - Phone:732-776-4524
Mailing Address - Fax:732-776-4639
Practice Address - Street 1:19 DAVIS AVE FL 7
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4488
Practice Address - Country:US
Practice Address - Phone:732-776-4524
Practice Address - Fax:732-776-4639
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA062854174400000X
NJ25MA062854002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7856506Medicaid
NJBA014331Medicare ID - Type Unspecified
NJ7856506Medicaid
NJ014331UWHMedicare PIN