Healthcare Provider Details

I. General information

NPI: 1801894076
Provider Name (Legal Business Name): TEOFILO S BAUTISTA M.D., P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 S LAKE ST
GARY IN
46403-2967
US

IV. Provider business mailing address

8135 CALUMET AVE
MUNSTER IN
46321-1701
US

V. Phone/Fax

Practice location:
  • Phone: 219-938-4481
  • Fax: 219-938-6480
Mailing address:
  • Phone: 219-513-2000
  • Fax: 219-513-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01032450
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: