Provider Demographics
NPI:1760043822
Name:BAKER, RUSSELL BARRE
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:BARRE
Last Name:BAKER
Suffix:
Gender:M
Credentials:
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:309 11TH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-1435
Practice Address - Country:US
Practice Address - Phone:502-732-3280
Practice Address - Fax:502-732-3284
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY247793213E00000X, 213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300084017Medicaid
KY7100919580Medicaid