MEDICARE: DR. VIDEONA B BAUTISTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME0029452	FL

General Provider Information

NPI Number	:	1003992017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIDEONA B BAUTISTA M.D.

Provider Business Mailing Address
First Line	:	1524 SE 3RD AVE
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33316-2502
Country	:	US
Telephone Number	:	954-763-6188
Fax Number	:	954-763-6199

Provider Business Practice Location Address
First Line	:	1524 SE 3RD AVE.
Second Line	:
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33316-2502
Country	:	US
Telephone Number	:	954-763-6188
Fax Number	:	951-763-6199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	07/08/2007

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