1295710754 NPI number — DR. BRADLEY W. BAKOTIC DO

Table of content: MOYOHOENA WILSON (NPI 1720408040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295710754 NPI number — DR. BRADLEY W. BAKOTIC DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKOTIC
Provider First Name:
BRADLEY
Provider Middle Name:
W.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1295710754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6039
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALMOUTH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04105-6039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-302-3045
Provider Business Mailing Address Fax Number:
207-347-7401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 WESTSIDE PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30004-8514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-376-7284
Provider Business Practice Location Address Fax Number:
770-475-0533
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZD0900X , with the licence number:  OS8431 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: OS8431 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZD0900X , with the licence number: 048594 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 262219000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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