1588693055 NPI number — SUSAN BALDWIN OD

Table of content: SUSAN BALDWIN OD (NPI 1588693055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588693055 NPI number — SUSAN BALDWIN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALDWIN
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1588693055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6435 OAKCREEK WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CITRUS HEIGHTS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95621-6105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-961-0395
Provider Business Mailing Address Fax Number:
916-961-0396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 BLUE RAVINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-961-0395
Provider Business Practice Location Address Fax Number:
916-961-0396
Provider Enumeration Date:
06/30/2006

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:  11460T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 050643 . This is a "NVA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 13748 . This is a "MEDICAL EYE SERIVCES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 941530 . This is a "EYEMED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD0114600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00008191 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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