Provider Demographics
NPI:1740273937
Name:BAKER, MISTY DAWN (DPM)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:DAWN
Last Name:BAKER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:DAWN
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6518
Mailing Address - Country:US
Mailing Address - Phone:903-757-3338
Mailing Address - Fax:
Practice Address - Street 1:305 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6518
Practice Address - Country:US
Practice Address - Phone:903-757-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1758213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176132202Medicaid
TX8EC351OtherBCBS PIN
TX8BG720OtherBCBS PIN
TX176132203Medicaid
TXP00439882OtherMEDICARE RAILROAD
TXV06813Medicare UPIN
TX323623YWKZMedicare PIN
TX176132202Medicaid