Provider Demographics
NPI:1215023940
Name:LAKEWOOD SURGICAL UROLOGY PS
Entity Type:Organization
Organization Name:LAKEWOOD SURGICAL UROLOGY PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-581-7000
Mailing Address - Street 1:PO BOX 97115
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0115
Mailing Address - Country:US
Mailing Address - Phone:253-588-7911
Mailing Address - Fax:253-984-6774
Practice Address - Street 1:11306 BRIDGEPORT WAY SW
Practice Address - Street 2:SUITE D
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3005
Practice Address - Country:US
Practice Address - Phone:253-581-7000
Practice Address - Fax:253-984-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044997208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH38737Medicare UPIN