Healthcare Provider Details

I. General information

NPI: 1366577751
Provider Name (Legal Business Name): ALLEN WAYNE BAKER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15972 SW TUALATIN SHERWOOD RD
SHERWOOD OR
97140-8690
US

IV. Provider business mailing address

15972 SW TUALATIN SHERWOOD RD
SHERWOOD OR
97140-8690
US

V. Phone/Fax

Practice location:
  • Phone: 503-625-5665
  • Fax: 503-625-3556
Mailing address:
  • Phone: 503-625-5665
  • Fax: 503-625-3556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1885ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: