Provider Demographics
NPI:1407032691
Name:SHELLY D. BAKER, OD, PC
Entity Type:Organization
Organization Name:SHELLY D. BAKER, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-341-3933
Mailing Address - Street 1:1252 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1364
Mailing Address - Country:US
Mailing Address - Phone:906-341-3933
Mailing Address - Fax:906-341-3944
Practice Address - Street 1:1252 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1364
Practice Address - Country:US
Practice Address - Phone:906-341-3933
Practice Address - Fax:906-341-3944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003805152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9006765000OtherBCBS OF MI
MI4173092Medicaid
MI9006765000OtherBCBS OF MI
MIOM92700Medicare PIN