Provider Demographics
NPI:1245671130
Name:BACA, MEGAN (OD)
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5131
Mailing Address - Country:US
Mailing Address - Phone:970-460-0154
Mailing Address - Fax:970-460-3032
Practice Address - Street 1:515 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5131
Practice Address - Country:US
Practice Address - Phone:970-460-0154
Practice Address - Fax:970-460-3032
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002989152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06021581Medicaid