Provider Demographics
NPI:1669583563
Name:BAKER, R. WAYNE (OD)
Entity type:Individual
Prefix:
First Name:R.
Middle Name:WAYNE
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 1:1455 OLD MCDONOUGH HWY SE STE A
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5979
Mailing Address - Country:US
Mailing Address - Phone:770-922-4900
Mailing Address - Fax:770-922-1563
Practice Address - Street 1:1455A OLD MCDONOUGH RD.SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5979
Practice Address - Country:US
Practice Address - Phone:770-922-4900
Practice Address - Fax:770-922-1563
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000746T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4268778OtherAETNA
GA00003242CMedicaid
GA11584OtherAVESIS
GAGA3468OtherEYEMED
GA1830205OtherPMCS
GA612585OtherANTHEM BCBS
GA612585OtherANTHEM BCBS
U19672Medicare UPIN
GA00003242CMedicaid