Provider Demographics
NPI:1912969338
Name:BAKER, JONATHAN C (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
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:RIVERSIDE PEDIATRICS
Mailing Address - Street 2:9659 RIVERSIDE DR
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7305
Mailing Address - Country:US
Mailing Address - Phone:918-299-5040
Mailing Address - Fax:918-299-9041
Practice Address - Street 1:RIVERSIDE PEDIATRICS
Practice Address - Street 2:9659 RIVERSIDE DR
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-7305
Practice Address - Country:US
Practice Address - Phone:918-299-5040
Practice Address - Fax:918-299-9041
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100123970AMedicaid
OK100123970AMedicaid