Provider Demographics
NPI:1356411979
Name:BAKER, SHELBY (OD)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BAKER
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 1:17 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-4413
Mailing Address - Country:US
Mailing Address - Phone:609-386-0352
Mailing Address - Fax:609-386-3702
Practice Address - Street 1:17 W BROAD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4413
Practice Address - Country:US
Practice Address - Phone:609-386-0352
Practice Address - Fax:609-386-3702
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00375000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1421603Medicaid
047192Medicare ID - Type Unspecified