Healthcare Provider Details

I. General information

NPI: 1457778383
Provider Name (Legal Business Name): RYAN ALLEN BAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1854 OAK GROVE BLVD
LUTZ FL
33559-8605
US

IV. Provider business mailing address

4033 TAMPA RD STE 101
OLDSMAR FL
34677-3224
US

V. Phone/Fax

Practice location:
  • Phone: 813-948-6133
  • Fax: 813-948-3460
Mailing address:
  • Phone: 813-854-2003
  • Fax: 813-436-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40493
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME144985
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: