Provider Demographics
NPI:1053492835
Name:BAKER, LAWRENCE VERNON
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:VERNON
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 HIGHWAY 78 E
Mailing Address - Street 2:MED ARTS TOWER STE 502
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-8907
Mailing Address - Country:US
Mailing Address - Phone:205-221-4916
Mailing Address - Fax:205-221-4939
Practice Address - Street 1:3400 HIGHWAY 78 E
Practice Address - Street 2:MED ARTS TOWER STE 502
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8907
Practice Address - Country:US
Practice Address - Phone:205-221-4916
Practice Address - Fax:205-221-4939
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7350208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528300590Medicaid
AL528300590Medicaid
ALC70576Medicare UPIN