Healthcare Provider Details

I. General information

NPI: 1386967982
Provider Name (Legal Business Name): CHARISMA BAUTISTA EVANGELISTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP BLDG 4554
LACKLAND AFB TX
78236
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 4554
LACKLAND AFB TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-2798
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License NumberT4153
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: