Healthcare Provider Details

I. General information

NPI: 1306232467
Provider Name (Legal Business Name): NIKOLAS DEVENDERAN BAKSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD # L-579
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax:
Mailing address:
  • Phone: 503-494-8211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number036159741
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: