Provider Demographics
NPI:1467448738
Name:BAYLESS, JOHN DAVID (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:BAYLESS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4785 HAYES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-7364
Mailing Address - Country:US
Mailing Address - Phone:319-356-2063
Mailing Address - Fax:319-356-2587
Practice Address - Street 1:4785 HAYES RD STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-7364
Practice Address - Country:US
Practice Address - Phone:319-356-2063
Practice Address - Fax:319-356-2587
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00438103G00000X, 103T00000X, 103TF0200X, 103TM1800X
WI3083-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA49666OtherWELLMARK BCBS
IA49666OtherWELLMARK BCBS
S81046Medicare UPIN
IA680011514Medicare PIN