Provider Demographics
NPI:1952530594
Name:BAKER, MARK DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:BAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:2000 W GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1029
Practice Address - Country:US
Practice Address - Phone:814-868-1088
Practice Address - Fax:814-868-1094
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006249L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010935600018Medicaid
PA0010935600007Medicaid
PA0010935600013Medicaid
PA0010935600016Medicaid
PA0010935600006Medicaid
PA0010935600012Medicaid
PA0010935600015Medicaid
PA0010935600008Medicaid
PA0010935600009Medicaid
PA0010935600011Medicaid
PA0010935600014Medicaid
PA0010935600013Medicaid