Healthcare Provider Details

I. General information

NPI: 1740455120
Provider Name (Legal Business Name): FERLEINE BAUTISTA-BEAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 PACIFIC AVE
LONG BEACH CA
90806-2613
US

IV. Provider business mailing address

PO BOX 51146
IRVINE CA
92619-1146
US

V. Phone/Fax

Practice location:
  • Phone: 657-201-9684
  • Fax:
Mailing address:
  • Phone: 657-201-9684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA113972
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: