Healthcare Provider Details

I. General information

NPI: 1457524555
Provider Name (Legal Business Name): MICHAEL L. BAIRD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 YELLOWSTONE AVE
CHUBBUCK ID
83202-2420
US

IV. Provider business mailing address

966 OLD GLORY WAY
CHUBBUCK ID
83202-1779
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-2020
  • Fax: 208-230-2069
Mailing address:
  • Phone: 208-709-0540
  • Fax: 208-238-2069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP967
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: