Provider Demographics
NPI:1821305269
Name:BAKSTON, DANIEL ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ALEXANDER
Last Name:BAKSTON
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 1:835 S. WOLCOTT AVE E-144
Mailing Address - Street 2:UNIVERSITY OF ILLINOIS MEDICAL CENTER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4006
Mailing Address - Country:US
Mailing Address - Phone:312-413-0369
Mailing Address - Fax:
Practice Address - Street 1:835 S. WOLCOTT AVE E-144
Practice Address - Street 2:UNIVERSITY OF ILLINOIS MEDICAL CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4006
Practice Address - Country:US
Practice Address - Phone:312-413-0369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01080808A2083X0100X
IL1250603242083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine