Provider Demographics
NPI:1336792845
Name:BAUTISTA, CARLOS G SR
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:G
Last Name:BAUTISTA
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1903
Mailing Address - Country:US
Mailing Address - Phone:872-239-0010
Mailing Address - Fax:844-803-7433
Practice Address - Street 1:1643 N 20TH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1903
Practice Address - Country:US
Practice Address - Phone:872-239-0010
Practice Address - Fax:844-803-7433
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver