Provider Demographics
NPI:1346312089
Name:BAK, J RANDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:RANDOLPH
Last Name:BAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JONGCHUL
Other - Middle Name:RANDOLPH
Other - Last Name:BAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2000 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1650
Mailing Address - Country:US
Mailing Address - Phone:617-417-7234
Mailing Address - Fax:
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1650
Practice Address - Country:US
Practice Address - Phone:617-243-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027729208000000X
MA230693208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics