Provider Demographics
NPI:1528167723
Name:BAUTISTA, MARIA CORAZON (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:CORAZON
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:858-722-4779
Mailing Address - Fax:
Practice Address - Street 1:11878 AVENUE OF INDUSTRY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3423
Practice Address - Country:US
Practice Address - Phone:858-722-4779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41768207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A417680Medicaid
CA00A417680Medicaid
A41768Medicare ID - Type Unspecified