Provider Demographics
NPI:1386634301
Name:BAXTER, MARK C (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:BAXTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:421 W STONE DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3269
Mailing Address - Country:US
Mailing Address - Phone:423-245-4100
Mailing Address - Fax:423-245-0463
Practice Address - Street 1:421 W STONE DR
Practice Address - Street 2:SUITE 6
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3269
Practice Address - Country:US
Practice Address - Phone:423-245-4100
Practice Address - Fax:423-245-0463
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000357213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100010536OtherPHP
VA216412OtherANTHEM
62-1402649OtherEMPLOYER IDENTIFICATION #
TN480007576OtherUNITED HEALTH CARE RAIL R
TN7510238OtherAETNA
TN3351572Medicaid
TN621402649OtherUNITED HEALTH CARE RIVER
VA0093-2019-9OtherVA MEDICAID
TN89548OtherBCBS OF TN
TN3351572Medicaid
TN89548OtherBCBS OF TN
0127760001Medicare NSC