Provider Demographics
NPI:1659386076
Name:BAK, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:BAK
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-388-6200
Mailing Address - Fax:757-388-6201
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6200
Practice Address - Fax:757-388-6201
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245661207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA-004OtherTRICARE/CHAMPUS
VAPAROtherAETNA
VAPAROtherVIRGINIA HEALTH NETWORK
VA373343OtherANTHEM BC/BS (FIRST COLONIAL RD.)
VAPAROtherCIGNA
VAPAROtherCORVEL/CORCARE
VA10047408OtherSENTARA OPTIMA HEALTH
VA1659386076Medicaid
VAPAROtherUSA MANAGED CARE
VAPAROtherVIRGINIA PREMIER HEALTH
VAPAROtherMULTIPLAN
NC11764OtherBC/BS
VAPAROtherUNITED HEALTH CARE
VA373342OtherANTHEM BC/BS (GRESHAM DR.)
VAPAROtherFIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY
NC5911764Medicaid
NC5911764Medicaid
VA020112E30Medicare PIN