Provider Demographics
NPI:1568406148
Name:BAKER, TERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:BAKER
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 1:3200 CHANNING WAY
Mailing Address - Street 2:A-105
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7546
Mailing Address - Country:US
Mailing Address - Phone:208-552-9530
Mailing Address - Fax:208-522-6262
Practice Address - Street 1:3200 CHANNING WAY
Practice Address - Street 2:A-105
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-552-9530
Practice Address - Fax:208-522-6262
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8221207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805984700Medicaid
ID1100633Medicare PIN
ID805984700Medicaid