Basic Information
| Provider Information | |||||||||
| NPI: | 1215129549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACHA | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722235665 | ||||||||
| FaxNumber: | 7722235646 | ||||||||
| Practice Location | |||||||||
| Address1: | 2221 SE OCEAN BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349963341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722194026 | ||||||||
| FaxNumber: | 7722234919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2007 | ||||||||
| LastUpdateDate: | 11/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 5101017517 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | OS11728 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 14LT1 | 01 | FL | BCBS | OTHER | 005925800 | 05 | FL | MEDICAID |