Provider Demographics
NPI:1821081944
Name:BAKKEN, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
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 1:301 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1613
Mailing Address - Country:US
Mailing Address - Phone:563-382-2230
Mailing Address - Fax:
Practice Address - Street 1:1609 N ANKENY BLVD
Practice Address - Street 2:200
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4165
Practice Address - Country:US
Practice Address - Phone:515-964-2772
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18220207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA01100Medicare UPIN