Healthcare Provider Details

I. General information

NPI: 1306063169
Provider Name (Legal Business Name): DR MISTY D BAKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 BILL OWENS PKWY SUITE A
LONGVIEW TX
75605-2150
US

IV. Provider business mailing address

2840 BILL OWENS PKWY SUITE A
LONGVIEW TX
75605-2150
US

V. Phone/Fax

Practice location:
  • Phone: 903-753-3668
  • Fax: 903-753-3671
Mailing address:
  • Phone: 903-753-3668
  • Fax: 903-753-3671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberL1758
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberL1758
License Number StateTX

VIII. Authorized Official

Name: DR. MISTY D BAKER
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 903-753-3668