Provider Demographics
NPI:1073561510
Name:BAKER, KEVIN GRAY (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GRAY
Last Name:BAKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7272
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7272
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29412085R0202X
MIEMC00057702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200079860AMedicaid
OK200079860AMedicaid
OK246619310Medicare PIN
OKP00319007Medicare PIN
OKOK404925Medicare PIN