Provider Demographics
NPI:1982607339
Name:BAKER, MICHAEL P (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
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:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31502-0173
Mailing Address - Country:US
Mailing Address - Phone:912-285-5690
Mailing Address - Fax:912-285-5690
Practice Address - Street 1:2101 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6935
Practice Address - Country:US
Practice Address - Phone:912-285-5690
Practice Address - Fax:912-285-1753
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2013-01-22
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
GA0364972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000532034EMedicaid
GA000532034EMedicaid
GAE83673Medicare UPIN