Provider Demographics
NPI:1326602939
Name:BAKER, MATTHEW JERROD
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JERROD
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 1:300 W 2ND ST APT 156
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5232
Mailing Address - Country:US
Mailing Address - Phone:423-618-8325
Mailing Address - Fax:
Practice Address - Street 1:18646 OXNARD ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1411
Practice Address - Country:US
Practice Address - Phone:818-654-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program