Provider Demographics
NPI:1083633366
Name:BAKA, JOHN VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:VINCENT
Last Name:BAKA
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:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-0604
Mailing Address - Country:US
Mailing Address - Phone:501-778-1000
Mailing Address - Fax:501-778-1010
Practice Address - Street 1:1220 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2908
Practice Address - Country:US
Practice Address - Phone:501-778-1000
Practice Address - Fax:501-778-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0792174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5K157OtherBCBS
AR129634001Medicaid
ARG29099Medicare UPIN
AR129634001Medicaid