=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780778498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSE L. BAUTISTA, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 S. SUNSET AVE.
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-960-6999
-----------------------------------------------------
Fax | 626-337-1231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2716 S. ERIN CT.
-----------------------------------------------------
City | WALNUT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91789-4638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-665-6704
-----------------------------------------------------
Fax | 909-444-7622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSE LUZA BAUTISTA III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 626-665-6704
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A35250
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------