1669583563 NPI number — R. WAYNE BAKER OD

Table of content: R. WAYNE BAKER OD (NPI 1669583563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669583563 NPI number — R. WAYNE BAKER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKER
Provider First Name:
R.
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669583563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1455 OLD MCDONOUGH HWY SE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30094-5979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-922-4900
Provider Business Mailing Address Fax Number:
770-922-1563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1455A OLD MCDONOUGH RD.SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30094-5979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-922-4900
Provider Business Practice Location Address Fax Number:
770-922-1563
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  000746T , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4268778 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00003242C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11584 . This is a "AVESIS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: GA3468 . This is a "EYEMED" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1830205 . This is a "PMCS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 612585 . This is a "ANTHEM BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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