Healthcare Provider Details

I. General information

NPI: 1912054487
Provider Name (Legal Business Name): JIMMY MACK BAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 SANTA MARIA WAY
SANTA MARIA CA
93455-2118
US

IV. Provider business mailing address

2050 S BLOSSER RD
SANTA MARIA CA
93458-7310
US

V. Phone/Fax

Practice location:
  • Phone: 805-934-5400
  • Fax: 805-938-9207
Mailing address:
  • Phone: 805-361-8030
  • Fax: 805-361-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA44906
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: