Healthcare Provider Details

I. General information

NPI: 1518945344
Provider Name (Legal Business Name): JASON TODD BAKICH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 UNION AVE SUITE 147
DOVER OH
44622-3004
US

IV. Provider business mailing address

515 UNION AVE SUITE 147
DOVER OH
44622-3004
US

V. Phone/Fax

Practice location:
  • Phone: 330-339-6233
  • Fax: 330-364-8460
Mailing address:
  • Phone: 330-339-6233
  • Fax: 330-364-8460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003043
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: