1023033859 NPI number — JOHN V. BAKA M.D.P.A

Table of content: (NPI 1023033859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023033859 NPI number — JOHN V. BAKA M.D.P.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN V. BAKA M.D.P.A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023033859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 604
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72018-0604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-778-1000
Provider Business Mailing Address Fax Number:
501-778-1010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 MILITARY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-2908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-778-1000
Provider Business Practice Location Address Fax Number:
501-778-1010
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAKA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
VINCENT
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
501-778-1000

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  E0792 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16839000000 . This is a "QC" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 137424002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5K157 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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