Provider Demographics
NPI:1780778217
Name:BAKER, STEPHEN MARC (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARC
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 1:608 PEARL STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13061
Mailing Address - Country:US
Mailing Address - Phone:315-788-2020
Mailing Address - Fax:315-755-3937
Practice Address - Street 1:608 PEARL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2194
Practice Address - Country:US
Practice Address - Phone:315-788-2020
Practice Address - Fax:315-755-3937
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV-006508152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00381537OtherPALMETTO GBA-RR MC
NY02399159Medicaid
NYP00364925OtherPALMETTO GBA-RR MC
NYU91614Medicare UPIN
NYDD2172Medicare PIN
NYP00364925OtherPALMETTO GBA-RR MC