Provider Demographics
NPI:1851334767
Name:HARRIS BAKER, DERRALYN M (MD)
Entity Type:Individual
Prefix:
First Name:DERRALYN
Middle Name:M
Last Name:HARRIS BAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 DELAUNAY AVENUE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2204
Mailing Address - Country:US
Mailing Address - Phone:706-322-9599
Mailing Address - Fax:706-322-8332
Practice Address - Street 1:1315 DELAUNEY AVE
Practice Address - Street 2:SUITE201
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2367
Practice Address - Country:US
Practice Address - Phone:706-322-9599
Practice Address - Fax:706-322-8332
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052739207Q00000X
AL00026689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA311838518AMedicaid
GA311838518CMedicaid
GA311838518BMedicaid
AL632200004Medicaid
GA311838518BMedicaid