Provider Demographics
NPI:1760618151
Name:BAKER, TIMOTHY DARRELL
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DARRELL
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 1:9050 GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-9216
Mailing Address - Country:US
Mailing Address - Phone:330-219-3916
Mailing Address - Fax:
Practice Address - Street 1:9050 GILBERT RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9216
Practice Address - Country:US
Practice Address - Phone:330-219-3916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-31
Last Update Date:2009-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHQ124289172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver