1467602045 NPI number — MR. MICHAEL WALLACE BAKER OT

Table of content: MR. MICHAEL WALLACE BAKER OT (NPI 1467602045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467602045 NPI number — MR. MICHAEL WALLACE BAKER OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKER
Provider First Name:
MICHAEL
Provider Middle Name:
WALLACE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467602045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 KINGS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72032-9440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-329-5416
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5312 W 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72204-1852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-280-9195
Provider Business Practice Location Address Fax Number:
501-663-7267
Provider Enumeration Date:
09/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  OTR1585 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OTR1585 . This is a "ARKANSAS STATE MEDICAL BOARD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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