Provider Demographics
NPI:1083696967
Name:BAKER, WALLACE C (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:C
Last Name:BAKER
Suffix:
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 1:1880 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4315
Mailing Address - Country:US
Mailing Address - Phone:208-524-6633
Mailing Address - Fax:208-524-9952
Practice Address - Street 1:1880 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4315
Practice Address - Country:US
Practice Address - Phone:208-524-6633
Practice Address - Fax:208-524-9952
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM2619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010001770OtherBLUE SHIELD PROVIDER NUMB
ID000010027582OtherBLUE SHIELD GROUP
ID080097138OtherRR MEDICARE
ID8K123OtherBLUE CROSS GROUP
ID002796800Medicaid
ID266877OtherDMBA
ID1134140148OtherBAKER FAMILY GROUP NPI
ID72132OtherIDAHO BLUE CROSS PROVIDER
ID807937700Medicaid
IDDE1614OtherRR MEDICARE GRP
ID266877OtherDMBA
IDG26485Medicare UPIN
ID807937700Medicaid