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General NPI Number Information
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NPI Number | 1063514487
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Entity Type | Individual
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Provider Name | JOSE LUZA BAUTISTA III M.D.
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Gender | Male
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Dates
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Enumeration Date | 09/05/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2716 S ERIN CT
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City | WALNUT
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State | CA
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Zip | 91789-4638
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Country | US
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Telephone | 626-665-6704
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Fax | 626-337-1231
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Provider Business Mailing Address
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Address Line | 1300 S SUNSET AVE
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City | WEST COVINA
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State | CA
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Zip | 91790-3342
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Country | US
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Telephone | 626-960-6999
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Fax | 626-337-1231
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | A35250
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License Number State | CA
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