Provider Demographics
NPI:1730222472
Name:GEORGE M BAKOWSKI OD PC
Entity type:Organization
Organization Name:GEORGE M BAKOWSKI OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-227-2451
Mailing Address - Street 1:1133 ST. VINCENT AVE. # 216 SUITE 120
Mailing Address - Street 2:MALL ST. VINCENT
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4147
Mailing Address - Country:US
Mailing Address - Phone:318-221-8445
Mailing Address - Fax:318-227-2442
Practice Address - Street 1:1133 ST. VINCENT AVE # 216 SUITE 120
Practice Address - Street 2:MALL ST. VINCENT
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4147
Practice Address - Country:US
Practice Address - Phone:318-221-8445
Practice Address - Fax:318-227-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA738-359T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1150614Medicaid
LA1150614Medicaid