Provider Demographics
NPI:1215129549
Name:BACHA, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BACHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:2221 SE OCEAN BLVD
Practice Address - Street 2:STE 200
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3341
Practice Address - Country:US
Practice Address - Phone:772-219-4026
Practice Address - Fax:772-223-4919
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017517208600000X
FLOS11728208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14LT1OtherBCBS
FL005925800Medicaid
FL14LT1OtherBCBS