Provider Demographics
NPI:1013949304
Name:BAKOS, JOHN T (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:BAKOS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 SUNRISE AVE
Mailing Address - Street 2:SUITE 610
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4565
Mailing Address - Country:US
Mailing Address - Phone:916-347-7001
Mailing Address - Fax:916-304-1633
Practice Address - Street 1:729 SUNRISE AVE
Practice Address - Street 2:SUITE 610
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4565
Practice Address - Country:US
Practice Address - Phone:916-347-7001
Practice Address - Fax:916-304-1633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67792207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0005230257OtherAETNA PIN
CA00A677920OtherBLUE SHIELD
CA9331367OtherCIGNA
CA1447658OtherUNITED HEALTHCARE
CA00A6779200Medicaid
CA110208821OtherRAILROAD MEDICARE
CA912041562OtherTIN USED BY MANY INSURANCE COMPANIES
CA00A677920OtherBLUE SHIELD
CA912041562OtherTIN USED BY MANY INSURANCE COMPANIES