Provider Demographics
NPI:1780778498
Name:JOSE L. BAUTISTA, M.D., INC.
Entity type:Organization
Organization Name:JOSE L. BAUTISTA, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUZA
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:626-665-6704
Mailing Address - Street 1:2716 S. ERIN CT.
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-4638
Mailing Address - Country:US
Mailing Address - Phone:626-665-6704
Mailing Address - Fax:909-444-7622
Practice Address - Street 1:1300 S. SUNSET AVE.
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-960-6999
Practice Address - Fax:626-337-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35250208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A352500Medicaid
CA00A352500Medicaid
CAA35250Medicare ID - Type Unspecified