Provider Demographics
NPI:1124063391
Name:BAKER, ROBERT ALAN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
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 1:11701 32 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-0756
Mailing Address - Country:US
Mailing Address - Phone:904-880-5888
Mailing Address - Fax:904-880-0011
Practice Address - Street 1:11701-32 SAN JOSE BLVD
Practice Address - Street 2:SUITE 216
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223
Practice Address - Country:US
Practice Address - Phone:904-880-5888
Practice Address - Fax:904-880-0011
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0030503207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013893300Medicaid
FL172926OtherHEALTH EAST
FL013893300Medicaid
D67286Medicare UPIN