Provider Demographics
NPI:1700881950
Name:BAKER, MATTHEW T (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N UNIVERSITY AVE
Mailing Address - Street 2:STE 250
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6695
Mailing Address - Country:US
Mailing Address - Phone:801-374-9625
Mailing Address - Fax:801-374-9690
Practice Address - Street 1:1000 E 15 S
Practice Address - Street 2:STE 350
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651
Practice Address - Country:US
Practice Address - Phone:801-465-5602
Practice Address - Fax:801-465-4480
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI46844208600000X
UT2779781205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34534000Medicaid
I12299Medicare UPIN
WI34534000Medicaid