Provider Demographics
NPI:1437135290
Name:BAXTER, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:BAXTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0337
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8187
Practice Address - Street 1:2121 N 1700 W
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-8803
Practice Address - Country:US
Practice Address - Phone:801-773-4840
Practice Address - Fax:801-525-8187
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2632901205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0372Medicaid
UTD0372Medicaid
F76018Medicare UPIN
UT005536822Medicare ID - Type Unspecified
UT002241018Medicare ID - Type Unspecified