Provider Demographics
NPI:1679820245
Name:BAKER, MICHAEL LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
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 1:420 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1644
Mailing Address - Country:US
Mailing Address - Phone:213-680-1551
Mailing Address - Fax:
Practice Address - Street 1:420 E 3RD ST
Practice Address - Street 2:SUITE 603
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1644
Practice Address - Country:US
Practice Address - Phone:213-680-1551
Practice Address - Fax:213-680-2148
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT 14425 TLGOtherSTATE LICENSE