Healthcare Provider Details

I. General information

NPI: 1841456324
Provider Name (Legal Business Name): REBECCA JO BAKKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA JO KADLEC

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 13TH AVE S
FARGO ND
58103-3602
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51.013675
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11565
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15288
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: