Provider Demographics
NPI:1023093812
Name:BACZUK, REBECCA LYNNE (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:BACZUK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2388 BAYS EDGE AVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451
Mailing Address - Country:US
Mailing Address - Phone:410-991-4647
Mailing Address - Fax:443-458-7224
Practice Address - Street 1:200 N LAKEMONT AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3273
Practice Address - Country:US
Practice Address - Phone:407-303-1332
Practice Address - Fax:407-303-0347
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236813208100000X, 171000000X
FLME153039208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113813700Medicaid