MEDICARE: JOEL O BAUTISTA MD

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	208600000X	Surgery Physician	ME 102468	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	020019367	OTHER	MO	TRAVELERS MEDICARE

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	29232	OTHER	MO	ANTHEM BC/BS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700878253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL O BAUTISTA MD

Provider Business Mailing Address
First Line	:	151 VICTORIA COMMONS BLVD
Second Line	:	SUITE 105
City	:	DELAND
State	:	FL
Zip	:	32724-7700
Country	:	US
Telephone Number	:	386-943-7175
Fax Number	:	386-734-8825

Provider Business Practice Location Address
First Line	:	151 VICTORIA COMMONS BLVD
Second Line	:	SUITE 105
City	:	DELAND
State	:	FL
Zip	:	32724-7700
Country	:	US
Telephone Number	:	386-943-7175
Fax Number	:	386-734-8825

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	10/06/2010

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Directions to “ JOEL O BAUTISTA MD” Practice Location

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