1013949304 NPI number — DR. JOHN T BAKOS M.D., PHD

Table of content: DR. JOHN T BAKOS M.D., PHD (NPI 1013949304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013949304 NPI number — DR. JOHN T BAKOS M.D., PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKOS
Provider First Name:
JOHN
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PHD
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:
1013949304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
729 SUNRISE AVE
Provider Second Line Business Mailing Address:
SUITE 610
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95661-4565
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-347-7001
Provider Business Mailing Address Fax Number:
916-304-1633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
729 SUNRISE AVE
Provider Second Line Business Practice Location Address:
SUITE 610
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-4565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-347-7001
Provider Business Practice Location Address Fax Number:
916-304-1633
Provider Enumeration Date:
07/07/2006

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: 207R00000X , with the licence number:  A67792 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: A67792 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0005230257 . This is a "AETNA PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A677920 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 9331367 . This is a "CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1447658 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A6779200 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110208821 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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