Provider Demographics
NPI:1902888084
Name:BAUTISTA, ROGER (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CUMMINS DR STE D
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-6411
Mailing Address - Country:US
Mailing Address - Phone:510-851-7423
Mailing Address - Fax:
Practice Address - Street 1:115 MALL DR
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5786
Practice Address - Country:US
Practice Address - Phone:559-582-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42078207P00000X
GA70711207P00000X
CA20A9319207P00000X
FLOS19273207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine