Provider Demographics
NPI:1043236722
Name:BAKER, MICHAEL LEO (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEO
Last Name:BAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-741-8800
Mailing Address - Fax:662-741-2700
Practice Address - Street 1:29 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5146
Practice Address - Country:US
Practice Address - Phone:662-873-4361
Practice Address - Fax:662-873-2921
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2017-07-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS15475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123141Medicaid
MSH38191Medicare UPIN
MS0123141Medicaid