Provider Demographics
NPI:1316008204
Name:BAKER, MARCUS T (CPO/L)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:T
Last Name:BAKER
Suffix:
Gender:M
Credentials:CPO/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 COPPER COVE CIR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6835
Mailing Address - Country:US
Mailing Address - Phone:901-795-1776
Mailing Address - Fax:901-795-1738
Practice Address - Street 1:3125 MATLOCK RD
Practice Address - Street 2:STE 100
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2920
Practice Address - Country:US
Practice Address - Phone:682-323-5921
Practice Address - Fax:682-323-5974
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS332B00000X332B00000X
MS335E00000X335E00000X
TNPRO0000000069335E00000X
TNORT0000000093335E00000X
TX1829335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00376397Medicaid
AR162145716Medicaid
TN1455030Medicaid