Provider Demographics
NPI:1104015304
Name:JASON T BAKICH DPM LLC
Entity Type:Organization
Organization Name:JASON T BAKICH DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:BAKICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-899-4399
Mailing Address - Street 1:29101 HEALTH CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5270
Mailing Address - Country:US
Mailing Address - Phone:440-899-4399
Mailing Address - Fax:
Practice Address - Street 1:29101 HEALTH CAMPUS DR
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5270
Practice Address - Country:US
Practice Address - Phone:440-899-4399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003043213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2882939Medicaid
OHDH1917OtherRAILROAD MEDICARE
OH9322031Medicare PIN
OHDH1917OtherRAILROAD MEDICARE