Provider Demographics
NPI:1306858956
Name:PAYNE, THERESA BLAINE BAKER (DO)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:BLAINE BAKER
Last Name:PAYNE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:BLAINE
Other - Middle Name:BAKER
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32341-0185
Mailing Address - Country:US
Mailing Address - Phone:850-973-1215
Mailing Address - Fax:866-926-4163
Practice Address - Street 1:180 NW HAYNES ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2010
Practice Address - Country:US
Practice Address - Phone:850-973-1215
Practice Address - Fax:866-923-4163
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9255207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272752800Medicaid
FLP00281257OtherRAILROAD MEDICARE
FLI39506Medicare UPIN
FLU5245ZMedicare PIN