Provider Demographics
NPI:1780766097
Name:BAKANE, DEEPAK
Entity type:Individual
Prefix:MR
First Name:DEEPAK
Middle Name:
Last Name:BAKANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BATSON CT
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1426
Mailing Address - Country:US
Mailing Address - Phone:815-462-1200
Mailing Address - Fax:
Practice Address - Street 1:100 BATSON CT
Practice Address - Street 2:SUITE 204
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1426
Practice Address - Country:US
Practice Address - Phone:815-462-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL58289Medicare UPIN
ILK15830Medicare ID - Type Unspecified