Provider Demographics
NPI:1215110200
Name:TEOFILO S. BAUTISTA, M.D., P.C
Entity type:Organization
Organization Name:TEOFILO S. BAUTISTA, M.D., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TEOFILO
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-938-4481
Mailing Address - Street 1:642 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-2967
Mailing Address - Country:US
Mailing Address - Phone:219-938-4481
Mailing Address - Fax:219-938-6480
Practice Address - Street 1:642 S LAKE ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-2967
Practice Address - Country:US
Practice Address - Phone:219-938-4481
Practice Address - Fax:219-938-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032450A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND69692Medicare UPIN
IN492870AMedicare PIN