Provider Demographics
NPI:1982696530
Name:BAKER, JACK LEE (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEE
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:L
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4411 BLUEBONNET DR STE 109
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-2912
Mailing Address - Country:US
Mailing Address - Phone:281-772-7749
Mailing Address - Fax:281-574-1420
Practice Address - Street 1:10912 EAST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77029
Practice Address - Country:US
Practice Address - Phone:713-451-2900
Practice Address - Fax:713-451-2103
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2489174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE54731Medicare UPIN
TX85760RMedicare ID - Type UnspecifiedMEDICARE NUMBER