Healthcare Provider Details

I. General information

NPI: 1619955192
Provider Name (Legal Business Name): MARIO BAUTISTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VETERANS DR
JACKSON OH
45640-9586
US

IV. Provider business mailing address

272 HOSPITAL RD STE 6
CHILLICOTHEE OH
45601-9031
US

V. Phone/Fax

Practice location:
  • Phone: 740-395-8090
  • Fax: 740-395-8197
Mailing address:
  • Phone: 740-779-4275
  • Fax: 740-779-4257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2004-0547
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2004-0547
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.089012
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: