Healthcare Provider Details

I. General information

NPI: 1295710754
Provider Name (Legal Business Name): BRADLEY W. BAKOTIC DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 WESTSIDE PARKWAY SUITE 290
ALPHARETTA GA
30004-8514
US

IV. Provider business mailing address

PO BOX 6039
FALMOUTH ME
04105-6039
US

V. Phone/Fax

Practice location:
  • Phone: 877-376-7284
  • Fax: 770-475-0533
Mailing address:
  • Phone: 888-302-3045
  • Fax: 207-347-7401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberOS8431
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberOS8431
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number048594
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: