Provider Demographics
NPI:1144249327
Name:BAUTISTA, MARTIN (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-3624
Mailing Address - Country:US
Mailing Address - Phone:580-338-8700
Mailing Address - Fax:580-338-8600
Practice Address - Street 1:350 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-3624
Practice Address - Country:US
Practice Address - Phone:580-338-8700
Practice Address - Fax:580-338-8600
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19756207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100025580AMedicaid
OK100025580AMedicaid
OKG31190Medicare UPIN
$$$$$$$$$MMedicare PIN