Healthcare Provider Details

I. General information

NPI: 1114078995
Provider Name (Legal Business Name): MARCIANO DAVID BAUTISTA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MILE 187.5 GLENN HWY
GLENNALLEN AK
99588-0589
US

IV. Provider business mailing address

PO BOX 5 MILE 187.5 GLENN HWY
GLENNALLEN AK
99588-0589
US

V. Phone/Fax

Practice location:
  • Phone: 907-822-3203
  • Fax:
Mailing address:
  • Phone: 907-822-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35579
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4535
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013320
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: