Healthcare Provider Details

I. General information

NPI: 1093812539
Provider Name (Legal Business Name): WALTER MICHAEL BAKUN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: WALTER MICHAEL BAKUN MD

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 KOCH AVE
MORRIS PLAINS NJ
07950-4400
US

IV. Provider business mailing address

59 KOCH AVE
MORRIS PLAINS NJ
07950-4400
US

V. Phone/Fax

Practice location:
  • Phone: 973-539-1800
  • Fax: 973-889-8789
Mailing address:
  • Phone: 973-538-1800
  • Fax: 973-889-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberMA45488
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: