Provider Demographics
NPI:1902946056
Name:BAKER, TERRY RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:RICHARD
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 1:2300 SAGAMORE PARKWAY S
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904
Mailing Address - Country:US
Mailing Address - Phone:765-471-1515
Mailing Address - Fax:765-471-1453
Practice Address - Street 1:2300 SAGAMORE PARKWAY S
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904
Practice Address - Country:US
Practice Address - Phone:765-471-1515
Practice Address - Fax:765-471-1453
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001878A152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232220AMedicare PIN
INT89194Medicare UPIN