Healthcare Provider Details

I. General information

NPI: 1780778217
Provider Name (Legal Business Name): STEPHEN MARC BAKER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 PEARL ST
WATERTOWN NY
13601-2194
US

IV. Provider business mailing address

608 PEARL STREET
WATERTOWN NY
13061
US

V. Phone/Fax

Practice location:
  • Phone: 315-788-2020
  • Fax: 315-755-3937
Mailing address:
  • Phone: 315-788-2020
  • Fax: 315-755-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV-006508
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberTUV-006508
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: