Healthcare Provider Details

I. General information

NPI: 1992887798
Provider Name (Legal Business Name): SAM BAKER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 SPRINGFIELD MALL SPACE # 11045
SPRINGFIELD VA
22150-1714
US

IV. Provider business mailing address

9127 CRICKLEWOOD CT
VIENNA VA
22182-1702
US

V. Phone/Fax

Practice location:
  • Phone: 703-971-4739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002372
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: