Provider Demographics
NPI:1366491789
Name:BAKKEN, JOHAN SEPTIMUS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHAN
Middle Name:SEPTIMUS
Last Name:BAKKEN
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 1:1001 E SUPERIOR ST
Mailing Address - Street 2:SUITE L201
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2207
Mailing Address - Country:US
Mailing Address - Phone:218-249-3057
Mailing Address - Fax:
Practice Address - Street 1:1001 E SUPERIOR ST
Practice Address - Street 2:SUITE L201
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2207
Practice Address - Country:US
Practice Address - Phone:218-249-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31523207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN661088900Medicaid
MN661088900Medicaid
MND48378Medicare UPIN