Basic Information
| Provider Information | |||||||||
| NPI: | 1073566048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | ELISEO | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5855 BREMO RD | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042853225 | ||||||||
| FaxNumber: | 8042850360 | ||||||||
| Practice Location | |||||||||
| Address1: | 5855 BREMO RD | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042853225 | ||||||||
| FaxNumber: | 8042850360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101051604 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 541267736 | 01 | VA | CIGNA | OTHER | 30961 | 01 | VA | OPTIMA | OTHER | 541267736 | 01 | VA | UNITED HEALTHCARE | OTHER | 010024536 | 01 | VA | VA PREMIER | OTHER | 541267736 | 01 | VA | COMMERCIAL | OTHER | 002940C63 | 01 | VA | SECURE HORIZONS | OTHER | 010024536 | 05 | VA | MEDICAID | 230046 | 01 | VA | SOUTHERN HEALTH | OTHER | 44645 | 01 | VA | CARENET | OTHER | C06695 | 01 | VA | GROUP PTAN | OTHER | 002940C63 | 01 | VA | HUMANA GOLD | OTHER | 269001 | 01 | VA | BC/BS | OTHER | 4270015 | 01 | VA | AETNA | OTHER | 002940C63 | 01 | VA | OPTIMA MEDICARE | OTHER |