Provider Demographics
NPI:1740364496
Name:BAKER, CHARLES WESLEY (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WESLEY
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 1:7700 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2411
Mailing Address - Country:US
Mailing Address - Phone:313-875-5738
Mailing Address - Fax:313-875-5728
Practice Address - Street 1:2888 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2612
Practice Address - Country:US
Practice Address - Phone:313-875-5738
Practice Address - Fax:313-664-0811
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430 103 9100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2768354Medicaid
MIOM37210024Medicare ID - Type Unspecified
MI2768354Medicaid