Provider Demographics
NPI:1154376283
Name:BAKER, BRADLEY R (OD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
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 1:516 JAY ST
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-2436
Mailing Address - Country:US
Mailing Address - Phone:530-458-2020
Mailing Address - Fax:530-458-8977
Practice Address - Street 1:516 JAY ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2436
Practice Address - Country:US
Practice Address - Phone:530-458-2020
Practice Address - Fax:530-458-8977
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7125T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07805ZOtherBS GROUP
CAGSD004280OtherMEDICAL GRP #
CASD0071250Medicaid
CASD0071250Medicaid
CASD0071250Medicare PIN
CAT10477Medicare UPIN
CAZZZ07805ZOtherBS GROUP