Basic Information
| Provider Information | |||||||||
| NPI: | 1073754321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | FRANCISCO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 530 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525851 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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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 | 207L00000X | 31063 | OK | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 31063 | OK | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 390200000X | KY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 52172 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 52172 | 01 | KY | LICENSE | OTHER | K277960 | 01 | KY | MEDICARE | OTHER | 7100166170 | 05 | KY | MEDICAID | 300022245 | 05 | IN | MEDICAID |