Healthcare Provider Details

I. General information

NPI: 1700878253
Provider Name (Legal Business Name): JOEL O BAUTISTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 VICTORIA COMMONS BLVD SUITE 105
DELAND FL
32724-7700
US

IV. Provider business mailing address

151 VICTORIA COMMONS BLVD SUITE 105
DELAND FL
32724-7700
US

V. Phone/Fax

Practice location:
  • Phone: 386-943-7175
  • Fax: 386-734-8825
Mailing address:
  • Phone: 386-943-7175
  • Fax: 386-734-8825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME 102468
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: