Provider Demographics
NPI:1477724177
Name:BAK, BRIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:BAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6548 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-5067
Mailing Address - Country:US
Mailing Address - Phone:718-639-1234
Mailing Address - Fax:718-639-1233
Practice Address - Street 1:6548 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5067
Practice Address - Country:US
Practice Address - Phone:718-639-1234
Practice Address - Fax:718-639-1233
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor