Provider Demographics
NPI:1780973792
Name:BAUTISTA, MA THERESA CONCEPCION (MD)
Entity type:Individual
Prefix:
First Name:MA THERESA
Middle Name:CONCEPCION
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 MORRIS ST
Mailing Address - Street 2:STE 357
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1326
Mailing Address - Country:US
Mailing Address - Phone:304-388-3574
Mailing Address - Fax:304-388-6481
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:3 WEST ADMINISTRATION
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1326
Practice Address - Country:US
Practice Address - Phone:304-388-3574
Practice Address - Fax:304-388-6481
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV25853207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine