Provider Demographics
NPI:1184705741
Name:BACAK, RUSSELL BRYAN (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:BRYAN
Last Name:BACAK
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 1:2911 TEXAS AVE S STE 202
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5388
Mailing Address - Country:US
Mailing Address - Phone:979-695-3570
Mailing Address - Fax:979-695-3573
Practice Address - Street 1:2911 TEXAS AVE S STE 202
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5388
Practice Address - Country:US
Practice Address - Phone:979-695-3570
Practice Address - Fax:979-695-3573
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116306506Medicaid
TXP00139188OtherMEDICARE RAILROAD
TX8M1860OtherBLUE CROSS NUMBER
TXP00139188OtherMEDICARE RAILROAD
TXG82967Medicare UPIN