Provider Demographics
NPI:1124525118
Name:BAIRD, JARED WESLEY (DO)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:WESLEY
Last Name:BAIRD
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 1:1042 POLIFKA DR
Mailing Address - Street 2:
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152
Mailing Address - Country:US
Mailing Address - Phone:803-895-2273
Mailing Address - Fax:
Practice Address - Street 1:1042 POLIFKA DR
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152
Practice Address - Country:US
Practice Address - Phone:803-895-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE2078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124525118OtherTRICARE