Provider Demographics
NPI:1326159104
Name:PASCUAL, EDWIN BAUTISTA (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:BAUTISTA
Last Name:PASCUAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1651 N NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3923
Mailing Address - Country:US
Mailing Address - Phone:708-780-7400
Mailing Address - Fax:708-780-7423
Practice Address - Street 1:4941 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-1419
Practice Address - Country:US
Practice Address - Phone:708-780-7400
Practice Address - Fax:708-780-7423
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036067770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067770Medicaid
IL0031601680OtherBCBS
ILE 30989Medicare UPIN