Healthcare Provider Details

I. General information

NPI: 1215021720
Provider Name (Legal Business Name): GRACE SEVILLA BAUTISTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 ARROYO PARKWAY, SUITE 330
PASADENA CA
90640
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-5268
  • Fax:
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA045534
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA045534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: