Healthcare Provider Details

I. General information

NPI: 1285015255
Provider Name (Legal Business Name): GRETCHEN SIEFKER BAKOS D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S TAMIAMI TRL
SARASOTA FL
34239-3509
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-7080
  • Fax: 941-917-7085
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS17254
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: