Provider Demographics
NPI:1790707925
Name:BAKER, JUSTIN A (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3877
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-3877
Mailing Address - Country:US
Mailing Address - Phone:229-891-9016
Mailing Address - Fax:229-891-9185
Practice Address - Street 1:8 LAUREL CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6889
Practice Address - Country:US
Practice Address - Phone:229-891-9016
Practice Address - Fax:229-891-9185
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA060434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA902633979BMedicaid
GA902633979Medicaid
GA511I080534Medicare PIN
GA511I080199Medicare PIN