Provider Demographics
NPI:1083811400
Name:BAKER, COLLEEN DIANE (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:DIANE
Last Name:BAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:DIANE
Other - Last Name:WHALEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14011 BRUSH CREEK PL
Mailing Address - Street 2:
Mailing Address - City:ROCA
Mailing Address - State:NE
Mailing Address - Zip Code:68430-4403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14011 BRUSH CREEK PL
Practice Address - Street 2:
Practice Address - City:ROCA
Practice Address - State:NE
Practice Address - Zip Code:68430-4403
Practice Address - Country:US
Practice Address - Phone:402-354-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI179-320207R00000X
IN01080835A207R00000X
MO2018029425207R00000X
KY51797207R00000X
ND15546207R00000X
NY295094207R00000X
MN64041207R00000X
KS04-41692207R00000X
SD11003207R00000X
COCDR.0000156207R00000X
IAMD-45438207R00000X
TN59150207R00000X
MEMD22452207R00000X
MI4301115893207R00000X
NE25564207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1083811400Medicaid
NE47068731716Medicaid
NE099099072Medicare PIN