1730222472 NPI number — GEORGE M BAKOWSKI OD PC

Table of content: (NPI 1730222472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730222472 NPI number — GEORGE M BAKOWSKI OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE M BAKOWSKI OD PC
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:
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:
1730222472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1133 ST. VINCENT AVE. # 216 SUITE 120
Provider Second Line Business Mailing Address:
MALL ST. VINCENT
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71104-4147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-221-8445
Provider Business Mailing Address Fax Number:
318-227-2442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1133 ST. VINCENT AVE # 216 SUITE 120
Provider Second Line Business Practice Location Address:
MALL ST. VINCENT
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71104-4147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-221-8445
Provider Business Practice Location Address Fax Number:
318-227-2442
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAKOWSKI
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
318-227-2451

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  738-359T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1150614 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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