Healthcare Provider Details

I. General information

NPI: 1538847850
Provider Name (Legal Business Name): EDWIN ALEA BAUTISTA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 S MCCALL RD STE 21
ENGLEWOOD FL
34224-9517
US

IV. Provider business mailing address

2828 S MCCALL RD STE 21
ENGLEWOOD FL
34224-9517
US

V. Phone/Fax

Practice location:
  • Phone: 941-290-5111
  • Fax:
Mailing address:
  • Phone: 941-290-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC007353
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: