MEDICARE: CEDRIC M. BAUTISTA M.D., A MEDICAL CORPORATION

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	208600000X	Surgery Physician	A37997	CA

General Provider Information

NPI Number	:	1124392725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDRIC M. BAUTISTA M.D., A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 2010
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92244-2010
Country	:	US
Telephone Number	:	760-353-6200
Fax Number	:	760-353-9817

Provider Business Practice Location Address
First Line	:	1500 S IMPERIAL AVE
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-4241
Country	:	US
Telephone Number	:	760-353-6200
Fax Number	:	760-353-9817

Authorized Official
Title or Position	:	OWNER
Name	:	CEDRIC M BAUTISTA
Credential	:	M.D.
Telephone Number	:	760-353-6200

Provider Enumeration Date	:	02/28/2012
Last Update Date	:	02/28/2012

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