Provider Demographics
NPI:1942272679
Name:WYNNE BAKER, DENISE (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:WYNNE 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 1:101 E OLNEY AVE
Mailing Address - Street 2:#505
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:215-254-2630
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:5753 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144
Practice Address - Country:US
Practice Address - Phone:215-848-8800
Practice Address - Fax:215-848-6036
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043473L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00144549300006Medicaid
0000759712Medicare ID - Type Unspecified
F76251Medicare UPIN