Provider Demographics
NPI:1528092400
Name:BAUTISTA, MARIN (MD)
Entity type:Individual
Prefix:DR
First Name:MARIN
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:14050 TOWN LOOP BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-6190
Mailing Address - Country:US
Mailing Address - Phone:407-348-0399
Mailing Address - Fax:407-348-8350
Practice Address - Street 1:14050 TOWN LOOP BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6190
Practice Address - Country:US
Practice Address - Phone:407-348-0399
Practice Address - Fax:407-348-8350
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-05-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME62124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593268906OtherTAX IDENTICATION NUMBER
FL370827600Medicaid
FL593268906OtherTAX IDENTICATION NUMBER
FL370827600Medicaid