Provider Demographics
NPI:1386967982
Name:EVANGELISTA, CHARISMA BAUTISTA (MD)
Entity type:Individual
Prefix:
First Name:CHARISMA
Middle Name:BAUTISTA
Last Name:EVANGELISTA
Suffix:
Gender:
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-2798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT4153207WX0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist