Provider Demographics
NPI:1548334139
Name:BACCHUS, JOANNE N (MD)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:N
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 HICKORY ST
Mailing Address - Street 2:WEST SUITE
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-5044
Mailing Address - Country:US
Mailing Address - Phone:325-704-5120
Mailing Address - Fax:325-704-5123
Practice Address - Street 1:602 HICKORY ST
Practice Address - Street 2:WEST SUITE
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-5044
Practice Address - Country:US
Practice Address - Phone:325-704-5120
Practice Address - Fax:325-704-5123
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ81992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115869302Medicaid
TX115869302Medicaid
TX00U20JMedicare ID - Type Unspecified