1487616785 NPI number — BRUCE BAUKNIGHT MD

Table of content: BRUCE BAUKNIGHT MD (NPI 1487616785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487616785 NPI number — BRUCE BAUKNIGHT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUKNIGHT
Provider First Name:
BRUCE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1487616785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1908 N LAURENT ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77901-5458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-572-0333
Provider Business Mailing Address Fax Number:
361-371-7090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6123 COUNTRY CLUB DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORIA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77904-1672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-578-1430
Provider Business Practice Location Address Fax Number:
361-578-0876
Provider Enumeration Date:
04/04/2006

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: 207RH0002X , with the licence number:  D4925 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: D4925 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: D4925 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 099421203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8K1333 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 099421204 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161169101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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