Provider Demographics
NPI:1710962428
Name:BAKSH, TERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:BAKSH
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 1:2 LATHROP AVE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2309
Mailing Address - Country:US
Mailing Address - Phone:860-204-0883
Mailing Address - Fax:
Practice Address - Street 1:2 LATHROP AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2309
Practice Address - Country:US
Practice Address - Phone:860-204-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037796207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001377961Medicaid
CT110008575Medicare UPIN
CTG97062Medicare UPIN