Provider Demographics
NPI:1932285087
Name:MICHAEL BAIRD OPTOMETRY PC
Entity Type:Organization
Organization Name:MICHAEL BAIRD OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-529-5914
Mailing Address - Street 1:5379 S 45TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8020
Mailing Address - Country:US
Mailing Address - Phone:208-529-5914
Mailing Address - Fax:208-524-6562
Practice Address - Street 1:2300 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-6568
Practice Address - Fax:208-524-6562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1592901Medicare ID - Type Unspecified
IDU65871Medicare UPIN