Healthcare Provider Details

I. General information

NPI: 1659311660
Provider Name (Legal Business Name): IRENE H BAUTISTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17951 JEFFERSON PARK RD
CLEVELAND OH
44130-8439
US

IV. Provider business mailing address

18181 PEARL RD
STRONGSVILLE OH
44136-6949
US

V. Phone/Fax

Practice location:
  • Phone: 440-816-6414
  • Fax: 440-816-6421
Mailing address:
  • Phone: 440-816-6414
  • Fax: 440-816-6421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35048439B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: