Provider Demographics
NPI:1891825568
Name:BAXLEY, MICAH DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:DENNIS
Last Name:BAXLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 SE 1ST AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-0407
Mailing Address - Country:US
Mailing Address - Phone:352-368-2448
Mailing Address - Fax:
Practice Address - Street 1:3002 SE 1ST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-0407
Practice Address - Country:US
Practice Address - Phone:352-368-2448
Practice Address - Fax:352-368-7796
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC258342084P0800X
FLME1004942084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCI50507Medicare UPIN