Healthcare Provider Details

I. General information

NPI: 1043236722
Provider Name (Legal Business Name): MICHAEL LEO BAKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 S FOURTH ST
ROLLING FORK MS
39159-5146
US

IV. Provider business mailing address

702 MARTIN LUTHER KING ST
MOUND BAYOU MS
38762-9314
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-4361
  • Fax: 662-873-2921
Mailing address:
  • Phone: 662-741-8800
  • Fax: 662-741-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15475
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: