Healthcare Provider Details

I. General information

NPI: 1750374237
Provider Name (Legal Business Name): WARLITO AVILES BAUTISTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 SPRING ST
JEFFERSONVILLE IN
47130-3705
US

IV. Provider business mailing address

1311 SPRING ST
JEFFERSONVILLE IN
47130-3705
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-3032
  • Fax: 812-282-3059
Mailing address:
  • Phone: 812-282-3032
  • Fax: 812-282-3059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01026833A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01026833A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: