Provider Demographics
NPI:1972599827
Name:BAKER, MARK BRADLEY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRADLEY
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 1:6043 WINTHROP COMMERCE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4272
Mailing Address - Country:US
Mailing Address - Phone:813-685-0827
Mailing Address - Fax:813-655-4204
Practice Address - Street 1:6043 WINTHROP COMMERCE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4272
Practice Address - Country:US
Practice Address - Phone:813-685-0827
Practice Address - Fax:813-655-4204
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92552174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U5632AMedicare ID - Type Unspecified
FL1972599827Medicare PIN
FLI38483Medicare UPIN