Provider Demographics
NPI:1013442094
Name:BALTIERRA, ROBERT RAY
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAY
Last Name:BALTIERRA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8089 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-1079
Mailing Address - Country:US
Mailing Address - Phone:734-424-9230
Mailing Address - Fax:734-424-2576
Practice Address - Street 1:8089 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1079
Practice Address - Country:US
Practice Address - Phone:734-424-9230
Practice Address - Fax:734-424-2576
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005154152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C97655OtherBCBS
MI1013442094Medicaid
MI1497781868Medicaid