Provider Demographics
NPI:1831126697
Name:BAXTER, BRIAN D (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:BAXTER
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 1:1266 ESCALANTE DR STE 301
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8934
Mailing Address - Country:US
Mailing Address - Phone:970-828-2200
Mailing Address - Fax:970-828-2201
Practice Address - Street 1:1266 ESCALANTE DR STE 301
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-8934
Practice Address - Country:US
Practice Address - Phone:970-828-2200
Practice Address - Fax:970-828-2201
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR151TA719152W00000X
NMOPT-2024-0014152W00000X
COOPT.0004060152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051557540Medicaid
ALP00334247OtherRR MEDICARE
AL1831126697Medicaid
AL515-93468OtherBLUE CROSS BLUESHIELD
ALP00334247OtherRR MEDICARE
AL051557540Medicaid
AL051557540Medicare PIN