Provider Demographics
NPI:1659464816
Name:BAKER, JEREMY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:2043 FM 423
Practice Address - Street 2:STE 110
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-6640
Practice Address - Country:US
Practice Address - Phone:469-362-6522
Practice Address - Fax:469-362-6532
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-01614208000000X
TXM7023208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188079106Medicaid
TX188079106Medicaid
TX8J9195Medicare PIN
NC5900846Medicaid
I30993Medicare UPIN
TX188079105Medicaid
TXP01427310OtherRAILROAD MEDICARE PTAN