1316924590 NPI number — ANDREW J BALDUS O.D.

Table of content: ANDREW J BALDUS O.D. (NPI 1316924590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316924590 NPI number — ANDREW J BALDUS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALDUS
Provider First Name:
ANDREW
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316924590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 W PARADISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BEND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53095-9795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-454-7734
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 W PARADISE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BEND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53095-9795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-454-7734
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2616 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10445 . This is a "NVA-MEDFORD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39-1967186 . This is a "FEDERAL TAX ID-COLBY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 410046660 . This is a "RAILROAD MEDICARE-COLBY" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39-1229699 . This is a "FEDERAL TAX ID-MEDFORD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 391967186019 . This is a "BLUE CROSS BLUE SHIELD-CO" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 410046659 . This is a "RAILROAD MEDICARE-MEDFORD" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1271670001 . This is a "DMERC-COLBY GROUP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 2616 . This is a "LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38596900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391229699015 . This is a "BLUE CROSS BLUE SHIELD-ME" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 0474980001 . This is a "DMERC-MEDFORD GROUP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38715100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38715300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 74812 . This is a "SECURITY HEALTH PLAN-COLB" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 74813 . This is a "SECURITY HEALTH PLAN-MEDF" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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