Healthcare Provider Details

I. General information

NPI: 1003801796
Provider Name (Legal Business Name): JOHN BAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 SKYLINE DR
JACKSON TN
38301-3938
US

IV. Provider business mailing address

587 SKYLINE DR
JACKSON TN
38301-3938
US

V. Phone/Fax

Practice location:
  • Phone: 731-421-6510
  • Fax: 731-421-6500
Mailing address:
  • Phone: 731-421-6510
  • Fax: 731-421-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number28097
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: