Basic Information
Provider Information | |||||||||
NPI: | 1093812539 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAKUN | ||||||||
FirstName: | WALTER | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BAKUN | ||||||||
OtherFirstName: | WALTER | ||||||||
OtherMiddleName: | MICHAEL | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 59 KOCH AVE | ||||||||
Address2: |   | ||||||||
City: | MORRIS PLAINS | ||||||||
State: | NJ | ||||||||
PostalCode: | 079504400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735381800 | ||||||||
FaxNumber: | 9738898789 | ||||||||
Practice Location | |||||||||
Address1: | 59 KOCH AVE | ||||||||
Address2: |   | ||||||||
City: | MORRIS PLAINS | ||||||||
State: | NJ | ||||||||
PostalCode: | 079504400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735391800 | ||||||||
FaxNumber: | 9738898789 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2006 | ||||||||
LastUpdateDate: | 02/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | MA45488 | NJ | Y |   | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |   |
No ID Information.