=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336120310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE H BAKER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2005
-----------------------------------------------------
Last Update Date | 12/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 WATERS RIDGE STE A
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-219-0558
-----------------------------------------------------
Fax | 972-436-9273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3315 COLORADO BLVD SUITE 102
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76210-6884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-320-1708
-----------------------------------------------------
Fax | 940-565-5457
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | G7983
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------