Healthcare Provider Details

I. General information

NPI: 1275517070
Provider Name (Legal Business Name): MR. SAMUEL SUMPTER BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 SPANOS COURT SUITE 230
MODESTO CA
95355-2816
US

IV. Provider business mailing address

1401 SPANOS COURT SUITE 230
MODESTO CA
95355-7813
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-9661
  • Fax: 209-521-9307
Mailing address:
  • Phone: 209-521-9661
  • Fax: 209-521-9307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberG36900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: