Provider Demographics
NPI:1669463386
Name:BAKER, JERRY L
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2452
Mailing Address - Country:US
Mailing Address - Phone:315-363-6690
Mailing Address - Fax:315-361-4942
Practice Address - Street 1:581 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2452
Practice Address - Country:US
Practice Address - Phone:315-363-6690
Practice Address - Fax:315-361-4942
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003219152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1669463386Medicare NSC