Healthcare Provider Details

I. General information

NPI: 1669470134
Provider Name (Legal Business Name): SOLIVEN C BAUTISTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N MAYFAIR RD FL 4
WAUWATOSA WI
53226-4216
US

IV. Provider business mailing address

3106 WEDGEWOOD DR
COLGATE WI
53017-9570
US

V. Phone/Fax

Practice location:
  • Phone: 414-259-7246
  • Fax: 414-259-7544
Mailing address:
  • Phone: 414-732-1503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number44156-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: