Provider Demographics
NPI:1336256288
Name:BAKER, SHELLY D (OD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:D
Last Name:BAKER
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 1:1252 W LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1364
Mailing Address - Country:US
Mailing Address - Phone:906-341-3933
Mailing Address - Fax:906-341-3944
Practice Address - Street 1:1252 W LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1364
Practice Address - Country:US
Practice Address - Phone:906-341-3933
Practice Address - Fax:906-341-3944
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003805152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4173092Medicaid
MI9006765000OtherBCBS
900A760100OtherBLUE CROSS & BLUE SHIELD
MI4152181Medicaid
U67928Medicare UPIN
MI4152181Medicaid
MI4173092Medicaid