Provider Demographics
NPI:1730103953
Name:BAKER, MARTY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:ALLEN
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:705 SUMMIT CROSSING PL
Practice Address - Street 2:SUITE 150
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2137
Practice Address - Country:US
Practice Address - Phone:704-671-5300
Practice Address - Fax:704-671-6307
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200000009208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891292WMedicaid
NC1292WOtherBCBSNC
SC237446783OtherBCBSSC
SCN00009OtherSC MEDICAID
SCN00009OtherSC MEDICAID
NC2021722AMedicare PIN
NC2021722AMedicare PIN