Provider Demographics
NPI:1366441610
Name:KURTIS, BAYLOR W
Entity Type:Individual
Prefix:
First Name:BAYLOR
Middle Name:W
Last Name:KURTIS
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 1:2300 HIGHWAY 365
Mailing Address - Street 2:SUITE 670
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6256
Mailing Address - Country:US
Mailing Address - Phone:409-729-2262
Mailing Address - Fax:409-729-2449
Practice Address - Street 1:2300 HIGHWAY 365
Practice Address - Street 2:SUITE 670
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6256
Practice Address - Country:US
Practice Address - Phone:409-729-2262
Practice Address - Fax:409-729-2449
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2016-11-10
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
TXE4883207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035183501Medicaid
TX00NJ80Medicare ID - Type Unspecified
TX035183501Medicaid