Provider Demographics
NPI:1174549570
Name:BALDWIN, KENNETH LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LESLIE
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 ELLA ST
Mailing Address - Street 2:STE B-1
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4166
Mailing Address - Country:US
Mailing Address - Phone:805-546-8662
Mailing Address - Fax:805-546-8665
Practice Address - Street 1:1304 ELLA ST
Practice Address - Street 2:STE B-1
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4166
Practice Address - Country:US
Practice Address - Phone:805-546-8662
Practice Address - Fax:805-546-8665
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34268207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG34268OtherMEDICAL LICENSE NUMBER
CA77-0113784OtherTAXPAYER ID NUMBER
CAAB7759408OtherDEA NUMBER
CA77-0113784OtherTAXPAYER ID NUMBER