Provider Demographics
NPI:1063514487
Name:BAUTISTA, JOSE LUZA III (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUZA
Last Name:BAUTISTA
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:1300 S SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3342
Mailing Address - Country:US
Mailing Address - Phone:626-960-6999
Mailing Address - Fax:626-337-1231
Practice Address - Street 1:2716 S ERIN CT
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-4638
Practice Address - Country:US
Practice Address - Phone:626-665-6704
Practice Address - Fax:626-337-1231
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CAA35250208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A352500Medicaid
CAE98629Medicare UPIN
CAA35250Medicare ID - Type Unspecified