Provider Demographics
NPI:1962542670
Name:BARON, GARY MARK (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARK
Last Name:BARON
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 1:9132 W HEBER RD
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-5563
Mailing Address - Country:US
Mailing Address - Phone:714-394-1387
Mailing Address - Fax:
Practice Address - Street 1:8340 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-4101
Practice Address - Country:US
Practice Address - Phone:623-936-0613
Practice Address - Fax:623-936-0653
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1343152W00000X
CA12497TPA152W00000X
AZP659A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12497TPAOtherOPTOMETRY LICENSE NUMBER
AZP659AOtherTHERAPEUTIC DRUG LICENSE
AZ1343OtherOPTOMETRY LICENSE NUMBER
CA12497TPAOtherOPTOMETRY LICENSE NUMBER
AZP659AOtherTHERAPEUTIC DRUG LICENSE