Provider Demographics
NPI:1467587675
Name:BAKER, MATTHEW W (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:BAKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 LEEDS DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2422
Mailing Address - Country:US
Mailing Address - Phone:219-462-3679
Mailing Address - Fax:
Practice Address - Street 1:3901 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7314
Practice Address - Country:US
Practice Address - Phone:219-878-6668
Practice Address - Fax:219-878-1918
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002051B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U19821Medicare UPIN