Provider Demographics
NPI:1629146915
Name:BAKER, CARRIE GILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:GILLIAM
Last Name:BAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:E
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4348 SOUTHPOINT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0903
Mailing Address - Country:US
Mailing Address - Phone:904-281-1915
Mailing Address - Fax:
Practice Address - Street 1:4348 SOUTHPOINT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0903
Practice Address - Country:US
Practice Address - Phone:904-281-1915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40873207R00000X
FLME133852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05149Medicare PIN