Provider Demographics
NPI:1225030406
Name:BAKKE, RYAN SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:BAKKE
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 1:204 N 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-3135
Mailing Address - Country:US
Mailing Address - Phone:641-792-1273
Mailing Address - Fax:641-791-4852
Practice Address - Street 1:204 N 4TH AVE E
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-3135
Practice Address - Country:US
Practice Address - Phone:641-792-1273
Practice Address - Fax:641-791-4852
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3471207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
546840006OtherMEDICARE PTAN
IA0422048Medicaid
IA546830006OtherMEDICARE PTAN
IA35873OtherBCBS PROVIDER #
IA546830006OtherMEDICARE PTAN
H98668Medicare UPIN