Provider Demographics
NPI:1912099441
Name:BAUTISTA, RAYMUNDO SEVILLA (MD)
Entity Type:Individual
Prefix:
First Name:RAYMUNDO
Middle Name:SEVILLA
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 1:118 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741
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
Practice Address - Country:US
Practice Address - Phone:626-914-3871
Practice Address - Fax:626-963-2816
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52874207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A528740Medicaid
CAG39705Medicare ID - Type Unspecified
CA00A528740Medicaid