Provider Demographics
NPI:1346267291
Name:BAUTISTA DATOR, CARMEN S (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:S
Last Name:BAUTISTA DATOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3009
Mailing Address - Country:US
Mailing Address - Phone:315-343-2151
Mailing Address - Fax:315-343-2100
Practice Address - Street 1:177 W 4TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3009
Practice Address - Country:US
Practice Address - Phone:315-343-2151
Practice Address - Fax:315-343-2100
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2300280207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI02328Medicare UPIN
NYRA1224Medicare PIN