Healthcare Provider Details

I. General information

NPI: 1689691537
Provider Name (Legal Business Name): DAISY I .BAUTISTA, MD, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 WILSHIRE BLVD STE. 803
LOS ANGELES CA
90057-3605
US

IV. Provider business mailing address

1930 WILSHIRE BLVD STE. 803
LOS ANGELES CA
90057-3605
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-3968
  • Fax: 213-483-3495
Mailing address:
  • Phone: 213-483-3968
  • Fax: 213-483-3495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA36896
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA36896
License Number StateCA

VIII. Authorized Official

Name: DR. DAISY IBANEZ BAUTISTA
Title or Position: PRESIDENT OWNER
Credential: M.D.
Phone: 213-483-3968