Provider Demographics
NPI:1912066242
Name:CARMEN BAUTISTA-DATOR MD PC
Entity Type:Organization
Organization Name:CARMEN BAUTISTA-DATOR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA DATOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-343-2151
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2300280207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI02328Medicare UPIN
NYDD2908Medicare PIN