MEDICARE: DR. CONSTANCIO M BAUTISTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	16733	KY

General Provider Information

NPI Number	:	1417937962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONSTANCIO M BAUTISTA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 130
Second Line	:
City	:	MT WASHINGTON
State	:	KY
Zip	:	40047-0130
Country	:	US
Telephone Number	:	502-538-7425
Fax Number	:

Provider Business Practice Location Address
First Line	:	161 WEST ST
Second Line	:
City	:	MT WASHINGTON
State	:	KY
Zip	:	40047-7184
Country	:	US
Telephone Number	:	502-538-7425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	07/08/2007

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