Provider Demographics
NPI:1699790071
Name:BAKARICH, MICHAEL A (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BAKARICH
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 1:1602 VERNON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4129
Mailing Address - Country:US
Mailing Address - Phone:706-880-7252
Mailing Address - Fax:770-999-2687
Practice Address - Street 1:1602 VERNON RD STE 200
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4129
Practice Address - Country:US
Practice Address - Phone:706-880-7252
Practice Address - Fax:770-999-2687
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02655207V00000X
GA060793207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060793OtherGA LIC #
KY1224988OtherCHA
KY000000369572OtherANTHEN BC/BS
GA104792175AMedicaid
KY64023674Medicaid
KY7238699OtherAETNA HEALTH INS.
364489332OtherTAX I.D. NUMBER FOR RWHC
KY1224988OtherCHA
GA104792175AMedicaid