Healthcare Provider Details

I. General information

NPI: 1619553591
Provider Name (Legal Business Name): RAYMOND BAUTISTA DPM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 28TH ST STE 111
LONG BEACH CA
90806-2715
US

IV. Provider business mailing address

701 E 28TH ST STE 111
LONG BEACH CA
90806-2715
US

V. Phone/Fax

Practice location:
  • Phone: 562-269-0300
  • Fax:
Mailing address:
  • Phone: 562-269-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOND BAUTISTA
Title or Position: MEDICAL DIRECTOR
Credential: DPM
Phone: 562-269-0300