Provider Demographics
NPI:1265575062
Name:RAYMOND P. BAKOTIC, DO, PLLC
Entity type:Organization
Organization Name:RAYMOND P. BAKOTIC, DO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:P
Authorized Official - Last Name:BAKOTIC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:520-469-7351
Mailing Address - Street 1:1925 W ORANGE GROVE RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1143
Mailing Address - Country:US
Mailing Address - Phone:520-469-7351
Mailing Address - Fax:520-469-7355
Practice Address - Street 1:1925 W ORANGE GROVE RD
Practice Address - Street 2:SUITE 209
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1143
Practice Address - Country:US
Practice Address - Phone:520-469-7351
Practice Address - Fax:520-469-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ117222Medicare PIN