Healthcare Provider Details

I. General information

NPI: 1922003235
Provider Name (Legal Business Name): BEN FOWLER BAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/22/2006

III. Provider practice location address

3400 E FRANK PHILLIPS BLVD STE 202
BARTLESVILLE OK
74006-2407
US

IV. Provider business mailing address

3400 E FRANK PHILLIPS BLVD STE 202
BARTLESVILLE OK
74006-2407
US

V. Phone/Fax

Practice location:
  • Phone: 918-335-1515
  • Fax: 918-331-2519
Mailing address:
  • Phone: 918-335-1515
  • Fax: 918-331-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number12625
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: