Provider Demographics
NPI:1265494025
Name:NAYAK, BAIRANJE R (PHD OD)
Entity Type:Individual
Prefix:DR
First Name:BAIRANJE
Middle Name:R
Last Name:NAYAK
Suffix:
Gender:M
Credentials:PHD OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 PARK AVE W
Mailing Address - Street 2:SUITE R
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-2790
Mailing Address - Country:US
Mailing Address - Phone:419-529-6699
Mailing Address - Fax:419-529-6379
Practice Address - Street 1:1456 PARK AVE W
Practice Address - Street 2:SUITE R
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2790
Practice Address - Country:US
Practice Address - Phone:419-529-6699
Practice Address - Fax:419-529-6379
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4504/T1173152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2096155Medicaid
U58797Medicare UPIN
0791804Medicare ID - Type Unspecified