Provider Demographics
NPI:1902474166
Name:BAKER, DOMINIQUE ELISE (DO)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:ELISE
Last Name:BAKER
Suffix:
Gender:F
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:PSC 482 BOX 193
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-0002
Mailing Address - Country:US
Mailing Address - Phone:804-604-2172
Mailing Address - Fax:
Practice Address - Street 1:180 KOWAN
Practice Address - Street 2:
Practice Address - City:URASOE
Practice Address - State:OKINAWA
Practice Address - Zip Code:9012124
Practice Address - Country:JP
Practice Address - Phone:315-637-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine