Provider Demographics
NPI:1902893571
Name:BARON, RICKY W (OD)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:W
Last Name:BARON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:710 S 13TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1802
Practice Address - Country:US
Practice Address - Phone:260-724-4318
Practice Address - Fax:260-724-9776
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001733B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009935Medicaid
IN100146650AMedicaid
IN000000084907OtherANTHEM BCBS
IN5348017OtherAETNA
IN000000084907OtherANTHEM BCBS