Provider Demographics
NPI:1669470134
Name:BAUTISTA, SOLIVEN C (MD)
Entity type:Individual
Prefix:DR
First Name:SOLIVEN
Middle Name:C
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLGATE
Mailing Address - State:WI
Mailing Address - Zip Code:53017-9570
Mailing Address - Country:US
Mailing Address - Phone:414-732-1503
Mailing Address - Fax:
Practice Address - Street 1:201 N MAYFAIR RD FL 4
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-259-7246
Practice Address - Fax:414-259-7544
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44156-020208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI045873840OtherMEDICARE PTAN
WI045873840OtherMEDICARE PTAN