Provider Demographics
NPI:1093847733
Name:BAKER, GARY RONALD (H AID DISPENSER)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:RONALD
Last Name:BAKER
Suffix:
Gender:M
Credentials:H AID DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 W ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4042
Mailing Address - Country:US
Mailing Address - Phone:209-526-9883
Mailing Address - Fax:209-526-8681
Practice Address - Street 1:1150 W ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4042
Practice Address - Country:US
Practice Address - Phone:209-526-9883
Practice Address - Fax:209-526-8681
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207237700000X
CASL1875156F00000X
CACL325156FC0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASL1875OtherREGISTERED SPECTACLE LENS DISPENSER
CAZZZ71978ZMedicaid
CA#207OtherHEARING AID DISPENSER
CACL325OtherREGISTERED CONTACT LENS DISPENSER