Healthcare Provider Details

I. General information

NPI: 1497315394
Provider Name (Legal Business Name): SAUL JAVIER BAUTISTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD
GREENVILLE SC
29605-4210
US

IV. Provider business mailing address

701 GROVE RD
GREENVILLE SC
29605-4210
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-7844
  • Fax: 864-455-7848
Mailing address:
  • Phone: 864-455-7844
  • Fax: 864-455-7848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL82813
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number320049
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: