Provider Demographics
NPI:1700856218
Name:ALLEN, WILLIAM BAKER (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BAKER
Last Name:ALLEN
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 1:2435 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2026
Mailing Address - Country:US
Mailing Address - Phone:803-254-5140
Mailing Address - Fax:803-779-1279
Practice Address - Street 1:2435 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2026
Practice Address - Country:US
Practice Address - Phone:803-254-5140
Practice Address - Fax:803-779-1279
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9918174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC099182Medicaid
SC330002031OtherRAILROAD MEDICARE
SC330002031OtherRAILROAD MEDICARE