Individual
MR. MARIO BAUTISTA SY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1351 KIMBERLY RD, STE 100, BETTENDORF, IA 52722-4193
(563) 355-7733
(563) 355-9077
Mailing address
1351 KIMBERLY RD, STE 100, BETTENDORF, IA 52722-4193
(563) 355-7733
(563) 355-9077
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
34978
IA
207RH0003X
Hematology & Oncology Physician
Primary
34978
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2110700
—
IA
01
—
34565
WELLMARK BC BS
—
01
—
421423259
FEDERAL TAX INDENTIFICATI
—
Enumeration date
03/23/2006
Last updated
12/14/2012
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