Basic Information
Provider Information | |||||||||
NPI: | 1275580185 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAKST | ||||||||
FirstName: | ALAN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5401 S CONGRESS AVE STE 204 | ||||||||
Address2: |   | ||||||||
City: | LAKE WORTH | ||||||||
State: | FL | ||||||||
PostalCode: | 334626637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5619674118 | ||||||||
FaxNumber: | 5619673463 | ||||||||
Practice Location | |||||||||
Address1: | 5401 S CONGRESS AVE | ||||||||
Address2: | # 204 | ||||||||
City: | ATLANTIS | ||||||||
State: | FL | ||||||||
PostalCode: | 334626635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5619674118 | ||||||||
FaxNumber: | 5619673463 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 08/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 0101255502 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 036051310 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 2014-01915 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | ME79475 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 1275580185 | 05 | NC |   | MEDICAID | 262867800 | 05 | FL |   | MEDICAID | 1275580185 | 05 | VA |   | MEDICAID |