Provider Demographics
NPI:1457524555
Name:BAIRD, MICHAEL L (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BAIRD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 OLD GLORY WAY
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1779
Mailing Address - Country:US
Mailing Address - Phone:208-709-0540
Mailing Address - Fax:208-238-2069
Practice Address - Street 1:4240 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2420
Practice Address - Country:US
Practice Address - Phone:208-238-2020
Practice Address - Fax:208-230-2069
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU65871Medicare UPIN
ID1592900Medicare PIN