Provider Demographics
NPI:1942355375
Name:BAUM, TIMOTHY THOMAS (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:THOMAS
Last Name:BAUM
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2049 W PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6437
Mailing Address - Country:US
Mailing Address - Phone:440-992-4877
Mailing Address - Fax:801-459-8867
Practice Address - Street 1:2049 W PROSPECT RD
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6437
Practice Address - Country:US
Practice Address - Phone:440-992-4877
Practice Address - Fax:801-459-8867
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1996-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341707982-001OtherMEDICAL MUTUAL OHIO
OH34-1707982OtherEIN
OH341707982-001OtherMEDICAL MUTUAL OHIO