Healthcare Provider Details

I. General information

NPI: 1417937962
Provider Name (Legal Business Name): CONSTANCIO M BAUTISTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 WEST ST
MT WASHINGTON KY
40047-7184
US

IV. Provider business mailing address

PO BOX 130
MT WASHINGTON KY
40047-0130
US

V. Phone/Fax

Practice location:
  • Phone: 502-538-7425
  • Fax:
Mailing address:
  • Phone: 502-538-7425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16733
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: