Provider Demographics
NPI:1265756233
Name:BAKER, JOE BLUNT IV (MD)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:BLUNT
Last Name:BAKER
Suffix:IV
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 1:817 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2605
Mailing Address - Country:US
Mailing Address - Phone:505-715-7477
Mailing Address - Fax:
Practice Address - Street 1:12554 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727
Practice Address - Country:US
Practice Address - Phone:512-795-5100
Practice Address - Fax:512-795-5122
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR19292085P0229X, 2085R0202X
IL036.1402042085P0229X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX371577301Medicaid