Provider Demographics
NPI:1750374237
Name:BAUTISTA, WARLITO AVILES (MD)
Entity type:Individual
Prefix:MR
First Name:WARLITO
Middle Name:AVILES
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 1:1311 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3705
Mailing Address - Country:US
Mailing Address - Phone:812-282-3032
Mailing Address - Fax:812-282-3059
Practice Address - Street 1:1311 SPRING ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3705
Practice Address - Country:US
Practice Address - Phone:812-282-3032
Practice Address - Fax:812-282-3059
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026833A207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100075350AMedicaid
B28452Medicare UPIN
122750Medicare PIN