MEDICARE: TITUS LUKE BAKER IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman	098639276	TN

General Provider Information

NPI Number	:	1386179810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TITUS LUKE BAKER IDC

Provider Business Mailing Address
First Line	:	2695 SHOUP DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4268
Country	:	US
Telephone Number	:	931-335-9190
Fax Number	:

Provider Business Practice Location Address
First Line	:	2695 SHOUP DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4268
Country	:	US
Telephone Number	:	931-335-9190
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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Directions to “ TITUS LUKE BAKER IDC” Practice Location

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