Provider Demographics
NPI:1104856061
Name:BAACK, BRAD ROBIN (MD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:ROBIN
Last Name:BAACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4795 LARIMER PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-9021
Mailing Address - Country:US
Mailing Address - Phone:970-342-2222
Mailing Address - Fax:970-342-2233
Practice Address - Street 1:4795 LARIMER PKWY STE 150
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-9021
Practice Address - Country:US
Practice Address - Phone:970-342-2222
Practice Address - Fax:970-342-2233
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0039315207ND0101X, 207N00000X
CO39315207ND0900X, 207NS0135X, 207NS0135X
COCDRH.0039315207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17283779Medicaid
CO433328Medicare ID - Type Unspecified
CO17283779Medicaid
070015981Medicare PIN