Provider Demographics
NPI:1881654523
Name:BACCHUS, HAROLD MUSTAPHA JR (MD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:MUSTAPHA
Last Name:BACCHUS
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:12002 WOODBOURNE CT
Mailing Address - Street 2:
Mailing Address - City:FT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1952
Mailing Address - Country:US
Mailing Address - Phone:260-637-5303
Mailing Address - Fax:260-490-9195
Practice Address - Street 1:1719 CREMER AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-1052
Practice Address - Country:US
Practice Address - Phone:260-490-9150
Practice Address - Fax:260-490-9195
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2009-12-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01034833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000634416OtherANTHEM
IN200027190Medicaid
IN200027190Medicaid