Provider Demographics
NPI:1902950223
Name:BAKANAUSKAS, EGLE ASTA (MD)
Entity type:Individual
Prefix:DR
First Name:EGLE
Middle Name:ASTA
Last Name:BAKANAUSKAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EGLE
Other - Middle Name:ASTA
Other - Last Name:ZABLECKAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1455 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5559
Mailing Address - Country:US
Mailing Address - Phone:970-686-3950
Mailing Address - Fax:970-686-3960
Practice Address - Street 1:1455 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5559
Practice Address - Country:US
Practice Address - Phone:970-686-3950
Practice Address - Fax:970-686-3960
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56907311Medicaid
COP00877649OtherMEDICARE RAILROAD CARRIER PTAN
COCO307238Medicare PIN
COP00877649OtherMEDICARE RAILROAD CARRIER PTAN
COCOA102154Medicare PIN
H43854Medicare UPIN