Provider Demographics
NPI:1346246782
Name:BAKKER, KONRAD W (MD)
Entity Type:Individual
Prefix:DR
First Name:KONRAD
Middle Name:W
Last Name:BAKKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 THOMAS JOHNSON DR
Mailing Address - Street 2:STE 100
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4405
Mailing Address - Country:US
Mailing Address - Phone:301-694-0900
Mailing Address - Fax:301-694-0657
Practice Address - Street 1:172 THOMAS JOHNSON DR
Practice Address - Street 2:STE 100
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4405
Practice Address - Country:US
Practice Address - Phone:301-694-0900
Practice Address - Fax:301-694-0657
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00353222084N0400X
MDDOO353222084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0501704OtherEVERCARE
VA237076OtherANTHEM BC/BS
MD372721OtherMAMASI/MDIPA.OPT. CH. DME
MD4137502OtherAETNA PPO/MC/EPO
MD495169OtherNCPPO
MD186224OtherCOVENTRY
DC5113OtherBC/BC OF DC
MD526711100Medicaid
MD613465OtherMAMSI/MDIPA/OPT. CHOICE
MDZC6139OtherHEALTHNET
MD1306711010OtherCIGNA MD/VA
MDKFE9COOtherBC/BS OF MD
VA237074OtherANTHEM HEALTHKEEPERS
MD3327089OtherAETNA HMO
VA3473625OtherAETNA HMO
MD500310OtherUNITED HEALTHCARE
MD495169OtherNCPPO
MD610FMedicare UPIN
P00082559Medicare ID - Type UnspecifiedRAILROAD
MD526711100Medicaid
MD4137502OtherAETNA PPO/MC/EPO
MD372721OtherMAMASI/MDIPA.OPT. CH. DME
VA490962001Medicare NSC