Basic Information
| Provider Information | |||||||||
| NPI: | 1619955192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 HOSPITAL RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456019031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794275 | ||||||||
| FaxNumber: | 7407794257 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 VETERANS DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456409586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403958090 | ||||||||
| FaxNumber: | 7403958197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2004-0547 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 2004-0547 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208000000X | 35.089012 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 10016535 | 01 | NM | LOVELACE HEALTH/SALUD | OTHER | P00137209 | 01 | RAILROAD MEDICARE | OTHER | PROVP11655 | 01 | NM | MOLINA | OTHER | 201047701 | 01 | NM | PRESBYTERIAN HEALTH/SALUD | OTHER | 2711211 | 05 | OH | MEDICAID | 885808 | 01 | AZ | AHCCCS | OTHER | 99238071 | 05 | NM | MEDICAID | NM009R63 | 01 | NM | BC/BS | OTHER |