Healthcare Provider Details

I. General information

NPI: 1295798320
Provider Name (Legal Business Name): WAYNE L BAKOTIC D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6240 SHILOH RD
ALPHARETTA GA
30005-8347
US

IV. Provider business mailing address

6240 SHILOH RD
ALPHARETTA GA
30005-8347
US

V. Phone/Fax

Practice location:
  • Phone: 855-422-5628
  • Fax: 205-579-9387
Mailing address:
  • Phone: 855-422-5628
  • Fax: 205-579-9387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number051017
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: