Provider Demographics
NPI:1104365188
Name:BAKER, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WEST ARBOR DRIVE
Mailing Address - Street 2:MAIL CODE 7897
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 WEST ARBOR DRIVE
Practice Address - Street 2:MAIL CODE 7897
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:858-657-7876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC196294208800000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty