Provider Demographics
NPI:1962498634
Name:BAILES, A JACKSON (OD)
Entity Type:Individual
Prefix:MR
First Name:A
Middle Name:JACKSON
Last Name:BAILES
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 1:507 MULBERRY HEIGHTS RD
Mailing Address - Street 2:POMEROY
Mailing Address - City:POMEROY
Mailing Address - State:OH
Mailing Address - Zip Code:45769-9573
Mailing Address - Country:US
Mailing Address - Phone:740-992-3279
Mailing Address - Fax:740-992-6740
Practice Address - Street 1:507 MULBERRY HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:OH
Practice Address - Zip Code:45769-9573
Practice Address - Country:US
Practice Address - Phone:740-992-3279
Practice Address - Fax:740-992-6740
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3385T891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3385OtherEYEMED VISIONCARE
3112701294001OtherANTHEM BLUE CROSS BLUE SH
OH0391446Medicaid
31127012900OtherOHIO BUREAU OF WORKMENS C
WV0149736000Medicaid
410022337OtherPALMETTO GBA RAILROAD MED
4664951OtherAETNA
993607OtherCLARITY VISION
4851990001OtherADMINISTAR FEDERAL
OH3385OtherEYEMED VISIONCARE
BA0525152Medicare ID - Type Unspecified
3112701294001OtherANTHEM BLUE CROSS BLUE SH
31127012900OtherOHIO BUREAU OF WORKMENS C