Provider Demographics
NPI:1912935842
Name:BAUTISTA, EVANGELINE GUTIERREZ (MD)
Entity Type:Individual
Prefix:DR
First Name:EVANGELINE
Middle Name:GUTIERREZ
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E ANGELENO AVE
Mailing Address - Street 2:UNIT 203
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2947
Mailing Address - Country:US
Mailing Address - Phone:818-846-2116
Mailing Address - Fax:
Practice Address - Street 1:3631 CRENSHAW BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4869
Practice Address - Country:US
Practice Address - Phone:323-734-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC50704Medicare ID - Type Unspecified
CAD86512Medicare UPIN