Provider Demographics
NPI:1205022209
Name:BAKER, RONNY D
Entity Type:Individual
Prefix:
First Name:RONNY
Middle Name:D
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 1:3608 E 29TH ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3849
Mailing Address - Country:US
Mailing Address - Phone:979-260-9135
Mailing Address - Fax:979-260-9459
Practice Address - Street 1:3608 E 29TH ST
Practice Address - Street 2:SUITE 113
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3849
Practice Address - Country:US
Practice Address - Phone:979-260-9135
Practice Address - Fax:979-260-9459
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50423237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX022163202Medicaid