Healthcare Provider Details

I. General information

NPI: 1659758480
Provider Name (Legal Business Name): MATTHEW BAKOS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 WALDEMERE ST STE 504
SARASOTA FL
34239-2941
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-8525
  • Fax: 941-917-8526
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS16826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: