Provider Demographics
NPI:1306063169
Name:DR MISTY D BAKER
Entity type:Organization
Organization Name:DR MISTY D BAKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:903-753-3668
Mailing Address - Street 1:2840 BILL OWENS PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2150
Mailing Address - Country:US
Mailing Address - Phone:903-753-3668
Mailing Address - Fax:903-753-3671
Practice Address - Street 1:2840 BILL OWENS PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2150
Practice Address - Country:US
Practice Address - Phone:903-753-3668
Practice Address - Fax:903-753-3671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1758332B00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDG5248OtherMEDICARE RAILROAD
TX189758901Medicaid
TX0011RLOtherBCBS PIN
TXDG5248OtherMEDICARE RAILROAD
TX189758901Medicaid