Provider Demographics
NPI:1457365108
Name:BAKER, ROGER D (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
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 1:601 E MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3145
Mailing Address - Country:US
Mailing Address - Phone:870-935-6396
Mailing Address - Fax:870-935-4063
Practice Address - Street 1:601 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3145
Practice Address - Country:US
Practice Address - Phone:870-935-6396
Practice Address - Fax:870-935-4063
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2279152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110423722Medicaid
AR410009356OtherRAILROAD MEDICARE
AR492367933OtherMEDICARE ID-TYPE UNSPECIFIED
MO312635501OtherMISSOURI MEDICAID
AR110423722Medicaid
AR49236Medicare PIN