Provider Demographics
NPI:1295798320
Name:BAKOTIC, WAYNE L (DO)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:BAKOTIC
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 1:6240 SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-8347
Mailing Address - Country:US
Mailing Address - Phone:855-422-5628
Mailing Address - Fax:205-579-9387
Practice Address - Street 1:6240 SHILOH RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-8347
Practice Address - Country:US
Practice Address - Phone:855-422-5628
Practice Address - Fax:205-579-9387
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051017207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA075954118AMedicaid
GAI04946Medicare UPIN
GA075954118AMedicaid