Basic Information
| Provider Information | |||||||||
| NPI: | 1871580860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACA | ||||||||
| FirstName: | DINO | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224110 | ||||||||
| FaxNumber: | 5707683911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224260 | ||||||||
| FaxNumber: | 5707683704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS009525L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0017945380009 | 05 | PA | MEDICAID |