Provider Demographics
NPI:1760478879
Name:BAUER, RICK D (OD)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:D
Last Name:BAUER
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 1:109 W MAIN ST
Mailing Address - Street 2:P O BOX 296
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553-1506
Mailing Address - Country:US
Mailing Address - Phone:812-295-3163
Mailing Address - Fax:812-295-2356
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-1506
Practice Address - Country:US
Practice Address - Phone:812-295-3163
Practice Address - Fax:812-295-2356
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001964152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100175810AMedicaid
IN35-1517701OtherFEDERAL TAX ID
IN520220Medicare PIN
INT69283Medicare UPIN
IN35-1517701OtherFEDERAL TAX ID