Healthcare Provider Details

I. General information

NPI: 1780660415
Provider Name (Legal Business Name): ANGELINA A BAUTISTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 POWERS BLVD
PARMA OH
44129-5437
US

IV. Provider business mailing address

PO BOX 29220
PARMA OH
44129-0220
US

V. Phone/Fax

Practice location:
  • Phone: 440-743-4356
  • Fax:
Mailing address:
  • Phone: 440-743-4356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number35045794B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: