Provider Demographics
NPI:1588315212
Name:BAKER, JAVON I SR (BEP CERTIFICATE)
Entity type:Individual
Prefix:MR
First Name:JAVON
Middle Name:I
Last Name:BAKER
Suffix:SR
Gender:M
Credentials:BEP CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W FOREST AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3541
Mailing Address - Country:US
Mailing Address - Phone:312-914-7513
Mailing Address - Fax:
Practice Address - Street 1:222 W FOREST AVE APT 306
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-3541
Practice Address - Country:US
Practice Address - Phone:312-914-7513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB260-4297-8034172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver