Provider Demographics
NPI:1679689467
Name:BAKER, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:W R
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:625 AFRICA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9808
Mailing Address - Country:US
Mailing Address - Phone:614-714-0985
Mailing Address - Fax:614-714-0986
Practice Address - Street 1:625 AFRICA RD STE 200
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-9808
Practice Address - Country:US
Practice Address - Phone:614-714-0985
Practice Address - Fax:614-714-0986
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067314207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2066928Medicaid
OHBA4196039Medicare PIN
OHBA4280092Medicare PIN
OHBA4280091Medicare PIN
OH2066928Medicaid
INM400066038Medicare PIN