Provider Demographics
NPI:1861532913
Name:BAK, BRIAN CLAY (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:CLAY
Last Name:BAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 4TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4577
Mailing Address - Country:US
Mailing Address - Phone:605-753-2050
Mailing Address - Fax:
Practice Address - Street 1:1 5TH ST SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3778
Practice Address - Country:US
Practice Address - Phone:605-882-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD687111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7600120Medicaid
SD86572Medicare ID - Type Unspecified
SD7600120Medicaid