Individual
KEVIN RAY BAXTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
230 E DAY RD, STE 100, MISHAWAKA, IN 46545-3408
(574) 271-3939
(574) 271-3941
Mailing address
230 E DAY RD, STE 100, MISHAWAKA, IN 46545-3408
(574) 271-3939
(574) 271-3941
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
02004614A
IN
207W00000X
Ophthalmology Physician
510109282
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201292460
—
IN
01
—
204460004
MEDICARE PTAN
IN
Enumeration date
06/17/2011
Last updated
07/02/2015
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