Healthcare Provider Details

I. General information

NPI: 1780137778
Provider Name (Legal Business Name): DR. SAMANTHA TIMPOG BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 EMBARCADERO CTR # LL3
SAN FRANCISCO CA
94111-4106
US

IV. Provider business mailing address

589 ROCCA AVE
SOUTH SAN FRANCISCO CA
94080-2653
US

V. Phone/Fax

Practice location:
  • Phone: 415-772-8282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: