Provider Demographics
NPI:1639101488
Name:BAKER, TRACY M (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
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:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0179
Mailing Address - Country:US
Mailing Address - Phone:918-967-4560
Mailing Address - Fax:918-967-4582
Practice Address - Street 1:1505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2913
Practice Address - Country:US
Practice Address - Phone:918-967-3368
Practice Address - Fax:917-967-3351
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS25080207Q00000X
OK26593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS16936OtherCOVENTRY
KS4253OtherPHS
KS047743OtherBCBS
OK200205450AMedicaid
KS11001972OtherMULTIPLAN
KS100659OtherHPK
KS4253OtherPHS
G05537Medicare UPIN