Provider Demographics
NPI:1700878253
Name:BAUTISTA, JOEL O (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:O
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 1:151 VICTORIA COMMONS BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7700
Mailing Address - Country:US
Mailing Address - Phone:386-943-7175
Mailing Address - Fax:386-734-8825
Practice Address - Street 1:151 VICTORIA COMMONS BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-7700
Practice Address - Country:US
Practice Address - Phone:386-943-7175
Practice Address - Fax:386-734-8825
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 102468208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203716105Medicaid
MO29232OtherANTHEM BC/BS
MO020019367OtherTRAVELERS MEDICARE
MO000004007Medicare ID - Type Unspecified
MO203716105Medicaid