Provider Demographics
NPI:1083693998
Name:BACKES, CARL RAY (DO)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:RAY
Last Name:BACKES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2654
Mailing Address - Country:US
Mailing Address - Phone:614-722-4950
Mailing Address - Fax:614-722-4966
Practice Address - Street 1:555 S 18TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2654
Practice Address - Country:US
Practice Address - Phone:614-722-4950
Practice Address - Fax:614-722-4966
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340022372080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0263941Medicaid
KY64783160Medicaid
OH0263941Medicaid
OHBA4060682Medicare ID - Type Unspecified