Provider Demographics
NPI:1447258900
Name:BACKE, JOHN C JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:BACKE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 JOHN KNOX RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-4117
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:850-298-6050
Practice Address - Street 1:1328 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:PANACEA
Practice Address - State:FL
Practice Address - Zip Code:32346-2151
Practice Address - Country:US
Practice Address - Phone:850-984-4735
Practice Address - Fax:850-984-4742
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31713207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044872900Medicaid
FL99388OtherMEDICARE PART B, GROUP PTAN
FL62131OtherBCBS
FL62131YMedicare PIN
FL044872900Medicaid
FL101846Medicare Oscar/Certification