Healthcare Provider Details

I. General information

NPI: 1265635148
Provider Name (Legal Business Name): EARL LEWIN BAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 DIVISION STREET
DERBY CT
06418
US

IV. Provider business mailing address

591 WINGFOOT ROAD
ORANGE CT
06477-2743
US

V. Phone/Fax

Practice location:
  • Phone: 203-735-7421
  • Fax:
Mailing address:
  • Phone: 203-795-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number014213
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: