Healthcare Provider Details

I. General information

NPI: 1912128307
Provider Name (Legal Business Name): BRIAN L BAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 TOWER CIRCLE
SOMERSET KY
42503
US

IV. Provider business mailing address

PO BOX 3535
WEST SOMERSET KY
42564-3535
US

V. Phone/Fax

Practice location:
  • Phone: 606-772-3376
  • Fax: 606-677-0335
Mailing address:
  • Phone: 606-772-3376
  • Fax: 606-677-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number39921
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number39921
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2007011366
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: