Provider Demographics
NPI:1487962478
Name:BAKOURIS, MARTA
Entity type:Individual
Prefix:DR
First Name:MARTA
Middle Name:
Last Name:BAKOURIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9965 HUDSON PL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9401
Mailing Address - Country:US
Mailing Address - Phone:612-252-0047
Mailing Address - Fax:
Practice Address - Street 1:9965 HUDSON PL
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-9401
Practice Address - Country:US
Practice Address - Phone:612-252-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2787152W00000X
MN3213152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist