Provider Demographics
NPI:1700032927
Name:BAKE, AUDRA L (OD)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:L
Last Name:BAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:L
Other - Last Name:ROWSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3 WOODLAND RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1702
Mailing Address - Country:US
Mailing Address - Phone:781-979-0960
Mailing Address - Fax:781-979-0618
Practice Address - Street 1:3 WOODLAND RD
Practice Address - Street 2:SUITE 120
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1702
Practice Address - Country:US
Practice Address - Phone:781-979-0960
Practice Address - Fax:781-979-0618
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002123152W00000X
MA4795152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist