Provider Demographics
NPI:1124551197
Name:BAKER, BRANDON JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:JOHN
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 1:86 AMHERST RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT RIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48069-1206
Mailing Address - Country:US
Mailing Address - Phone:313-580-4058
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301501791207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program