=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912935842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVANGELINE GUTIERREZ BAUTISTA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3631 CRENSHAW BLVD SUITE 109
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90016-4869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-734-1414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 E ANGELENO AVE UNIT 203
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91502-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-846-2116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C50704
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------