Healthcare Provider Details

I. General information

NPI: 1477581320
Provider Name (Legal Business Name): JEFFREY L BAKKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 CENTRAL AVE
OSSEO MN
55369-1241
US

IV. Provider business mailing address

9201 W BROADWAY AVE STE 601
BROOKLYN PARK MN
55445-1924
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7900
  • Fax: 763-420-1901
Mailing address:
  • Phone: 763-587-7900
  • Fax: 763-587-7066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45512
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: