Provider Demographics
NPI:1669438982
Name:BAX, JOHN C (MD, PH D)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:BAX
Suffix:
Gender:M
Credentials:MD, PH D
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 7726
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-7079
Mailing Address - Country:US
Mailing Address - Phone:920-540-5112
Mailing Address - Fax:
Practice Address - Street 1:N2227 BUTTERNUT RD
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-9741
Practice Address - Country:US
Practice Address - Phone:920-540-5112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30839700Medicaid
WIB51432Medicare UPIN
WI000145232Medicare ID - Type Unspecified