Provider Demographics
NPI:1063413938
Name:BAK, JOHN B (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:BAK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11307 BRIDGEPORT WAY SW STE 217
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3024
Mailing Address - Country:US
Mailing Address - Phone:253-985-6134
Mailing Address - Fax:253-985-6137
Practice Address - Street 1:11307 BRIDGEPORT WAY SW STE 217
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3024
Practice Address - Country:US
Practice Address - Phone:253-985-6134
Practice Address - Fax:253-985-6137
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-11-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00044997208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0261681OtherSTATE L&I
WA0216025OtherSTATE L&I
WA0261684OtherSTATE L&I
WA0299315OtherSTATE L&I
WA7077449Medicaid
WAG8863285Medicare PIN
WA7077449Medicaid
WA0216025OtherSTATE L&I