Healthcare Provider Details

I. General information

NPI: 1568445872
Provider Name (Legal Business Name): MARK DOUGLAS BAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701
US

IV. Provider business mailing address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-8480
  • Fax: 727-767-8420
Mailing address:
  • Phone: 727-767-8480
  • Fax: 727-767-8420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberME136774
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: