Provider Demographics
NPI:1265448310
Name:BAKER, RANDOLPH MARSHALL (MD)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:MARSHALL
Last Name:BAKER
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:PO BOX 79777
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0777
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:33 REBECCA DR
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-6242
Practice Address - Country:US
Practice Address - Phone:434-654-4680
Practice Address - Fax:434-589-6688
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101259557207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVM197AMedicare PIN
G79237Medicare UPIN
GA110181000OtherRAILROAD MEDICARE
GABB5833606OtherDEA
GA00842641BMedicaid