Basic Information
Provider Information
NPI: 1003805086
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BAKER
FirstName: JOHN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2670 PEBBLE DAWN
Address2:  
City: SAN ANTONIO
State: TX
PostalCode: 782324118
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3851 ROGER BROOKE DR
Address2:  
City: FORT SAM HOUSTON
State: TX
PostalCode: 782344501
CountryCode: US
TelephoneNumber: 2109164735
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/21/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171W00000XH1733TXY Other Service ProvidersContractor 

No ID Information.


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