MEDICARE: DR. EVANGELINE GUTIERREZ BAUTISTA M.D.

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	207Q00000X	Family Medicine Physician	C50704	CA

General Provider Information

NPI Number	:	1912935842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVANGELINE GUTIERREZ BAUTISTA M.D.

Provider Business Mailing Address
First Line	:	201 E ANGELENO AVE
Second Line	:	UNIT 203
City	:	BURBANK
State	:	CA
Zip	:	91502-2947
Country	:	US
Telephone Number	:	818-846-2116
Fax Number	:

Provider Business Practice Location Address
First Line	:	3631 CRENSHAW BLVD
Second Line	:	SUITE 109
City	:	LOS ANGELES
State	:	CA
Zip	:	90016-4869
Country	:	US
Telephone Number	:	323-734-1414
Fax Number	:

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2007

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