Healthcare Provider Details

I. General information

NPI: 1710115456
Provider Name (Legal Business Name): RAYMUNDO S. BAUTISTA M.D. APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 E AMAR RD SUITE D
WEST COVINA CA
91792-1619
US

IV. Provider business mailing address

1523 E AMAR RD SUITE D
WEST COVINA CA
91792-1619
US

V. Phone/Fax

Practice location:
  • Phone: 626-839-9100
  • Fax: 626-839-9106
Mailing address:
  • Phone: 626-839-9100
  • Fax: 626-839-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA52874
License Number StateCA

VIII. Authorized Official

Name: DR. RAYMUNDO SEVILLA BAUTISTA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 626-839-9100