1295710754 NPI number — DR. BRADLEY W. BAKOTIC DO

Table of content: DR. BRADLEY W. BAKOTIC DO (NPI 1295710754)

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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