Provider Demographics
NPI:1033197629
Name:SUBBIAH, BAKKIAM (MD)
Entity Type:Individual
Prefix:
First Name:BAKKIAM
Middle Name:
Last Name:SUBBIAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-585-6200
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-475-8730
Practice Address - Fax:513-475-8033
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360491092084N0600X, 2084N0400X
OH351236252084N0400X, 2084N0600X
IA195252084N0600X, 2084N0400X
FLME885572084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0136OtherJOHN DEERE FAMILY
20957OtherWELLMARK
IAIA0151OtherJOHN DEERE FAMILY
IL8121085OtherBCBS
IL036049109Medicaid
050739OtherHEALTH ALLIANCE
15929OtherMIDLANDS CHOICE
20068OtherIA HEALTH SOLUTIONS
686137OtherFIRST HEALTH
IA1996108Medicaid
97295OtherWELLMARK
FLAA544YMedicare PIN
FLAA544WMedicare PIN
20957OtherWELLMARK
ILK10316Medicare ID - Type Unspecified
20957OtherWELLMARK