Healthcare Provider Details

I. General information

NPI: 1972509974
Provider Name (Legal Business Name): JAY P BAKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E EVERGREEN ST
SPRINGFIELD MO
65803-4300
US

IV. Provider business mailing address

108 S HICKORY ST
MOUNT VERNON MO
65712-1407
US

V. Phone/Fax

Practice location:
  • Phone: 417-823-2900
  • Fax: 417-886-2774
Mailing address:
  • Phone: 417-466-4110
  • Fax: 417-466-4255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number36747
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number36747
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number36747
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: