=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134224066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NORMAN C. BAUTISTA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 08/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1848 N ALVARADO ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-1781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-663-0465
-----------------------------------------------------
Fax | 323-953-6718
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 W COLLEGE ST STE 203
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90012-3177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-663-0465
-----------------------------------------------------
Fax | 323-953-6718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A60200
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------