Basic Information
| Provider Information | |||||||||
| NPI: | 1063413938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW STE 217 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539856134 | ||||||||
| FaxNumber: | 2539856137 | ||||||||
| Practice Location | |||||||||
| Address1: | 11307 BRIDGEPORT WAY SW STE 217 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539856134 | ||||||||
| FaxNumber: | 2539856137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD00044997 | WA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0261681 | 01 | WA | STATE L&I | OTHER | 0216025 | 01 | WA | STATE L&I | OTHER | 0261684 | 01 | WA | STATE L&I | OTHER | 0299315 | 01 | WA | STATE L&I | OTHER | 7077449 | 05 | WA | MEDICAID |