Provider Demographics
NPI:1982712899
Name:BAKER, JACK ROSS (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ROSS
Last Name:BAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:4590 DRESSLER ROAD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2546
Mailing Address - Country:US
Mailing Address - Phone:330-492-5555
Mailing Address - Fax:330-492-7808
Practice Address - Street 1:4590 DRESSLER ROAD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2546
Practice Address - Country:US
Practice Address - Phone:330-492-5555
Practice Address - Fax:330-492-7808
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003239B208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0672884Medicaid
BA0509465Medicare ID - Type Unspecified
OH0672884Medicaid