Individual
WALLACE C BAKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1880 JOHN ADAMS PKWY, IDAHO FALLS, ID 83401-4315
(208) 524-6633
(208) 524-9952
Mailing address
1880 JOHN ADAMS PKWY, IDAHO FALLS, ID 83401-4315
(208) 524-6633
(208) 524-9952
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
M2619
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010001770
BLUE SHIELD PROVIDER NUMB
ID
01
—
000010027582
BLUE SHIELD GROUP
ID
05
—
002796800
—
ID
01
—
080097138
RR MEDICARE
ID
01
—
1134140148
BAKER FAMILY GROUP NPI
ID
01
—
266877
DMBA
ID
01
—
72132
IDAHO BLUE CROSS PROVIDER
ID
05
—
807937700
—
ID
01
—
8K123
BLUE CROSS GROUP
ID
01
—
DE1614
RR MEDICARE GRP
ID
Enumeration date
11/16/2005
Last updated
07/19/2010
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