Provider Demographics
NPI:1124161542
Name:WASHINGTON D. BAQUERO, MD, PA
Entity type:Organization
Organization Name:WASHINGTON D. BAQUERO, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WASHINGTON
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAQUERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-275-4141
Mailing Address - Street 1:1705 COLONIAL BLVD
Mailing Address - Street 2:STE C-1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1195
Mailing Address - Country:US
Mailing Address - Phone:239-275-4141
Mailing Address - Fax:239-275-4879
Practice Address - Street 1:1705 COLONIAL BLVD
Practice Address - Street 2:STE C-1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1195
Practice Address - Country:US
Practice Address - Phone:239-275-4141
Practice Address - Fax:239-275-4879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038989700Medicaid
FL038989700Medicaid
FLK2633Medicare PIN