Provider Demographics
NPI:1164514246
Name:BAKER, JERALD F (MD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:F
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 1:606 N 3RD AVE
Mailing Address - Street 2:STE. 102
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1594
Mailing Address - Country:US
Mailing Address - Phone:208-265-1700
Mailing Address - Fax:208-265-1750
Practice Address - Street 1:606 N 3RD AVE
Practice Address - Street 2:STE. 102
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1594
Practice Address - Country:US
Practice Address - Phone:208-265-1700
Practice Address - Fax:208-265-1750
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3013174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID251200Medicaid
ID1107985Medicare ID - Type Unspecified
IDC36807Medicare UPIN