Provider Demographics
NPI:1104856061
Name:BAACK, BRAD ROBIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:ROBIN
Last Name:BAACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1850 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3212
Mailing Address - Country:US
Mailing Address - Phone:720-494-3118
Mailing Address - Fax:970-237-8035
Practice Address - Street 1:1850 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3212
Practice Address - Country:US
Practice Address - Phone:720-494-3118
Practice Address - Fax:970-237-8035
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39315207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
CODR.0039315207N00000X
COCDRH.0039315207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17283779Medicaid
CO433328Medicare ID - Type Unspecified
CO17283779Medicaid
070015981Medicare PIN