Healthcare Provider Details

I. General information

NPI: 1104856061
Provider Name (Legal Business Name): BRAD ROBIN BAACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 WOLVERINE DR STE F
MONTROSE CO
81401-4965
US

IV. Provider business mailing address

4700 EXCHANGE CT STE 110
BOCA RATON FL
33431-4450
US

V. Phone/Fax

Practice location:
  • Phone: 970-252-7444
  • Fax: 970-252-3446
Mailing address:
  • Phone: 561-948-0291
  • Fax: 561-859-0429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number39315
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number39315
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberDR.0039315
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDR.0039315
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: