MEDICARE: RAYMUNDO S BAUTISTA, MD, PROF CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	A52874	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	A52874	OTHER	CA	PRES. MEDICAL STATE LIC#

General Provider Information

NPI Number	:	1023143427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAYMUNDO S BAUTISTA, MD, PROF CORP

Provider Business Mailing Address
First Line	:	118 W FOOTHILL BLVD
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91741-3364
Country	:	US
Telephone Number	:	626-914-3871
Fax Number	:	626-963-2816

Provider Business Practice Location Address
First Line	:	118 W FOOTHILL BLVD
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91741-3364
Country	:	US
Telephone Number	:	626-914-3871
Fax Number	:	626-963-2816

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAYMUNDO SEVILLA BAUTISTA
Credential	:	M.D.
Telephone Number	:	626-914-3871

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	08/31/2012

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