Provider Demographics
NPI:1639176571
Name:BAKER, LISA A (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:BAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 E PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1915
Mailing Address - Country:US
Mailing Address - Phone:631-425-2121
Mailing Address - Fax:631-425-2193
Practice Address - Street 1:180 E PULASKI RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1915
Practice Address - Country:US
Practice Address - Phone:631-425-2121
Practice Address - Fax:631-425-2193
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188239-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01344063Medicaid
NY65K981Medicare PIN
NY01344063Medicaid