Provider Demographics
NPI:1316924590
Name:BALDUS, ANDREW J (OD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:BALDUS
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 1:1700 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:414-454-7734
Mailing Address - Fax:
Practice Address - Street 1:1700 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9795
Practice Address - Country:US
Practice Address - Phone:414-454-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2616152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10445OtherNVA-MEDFORD
WI39-1967186OtherFEDERAL TAX ID-COLBY
WI410046660OtherRAILROAD MEDICARE-COLBY
WI39-1229699OtherFEDERAL TAX ID-MEDFORD
WI391967186019OtherBLUE CROSS BLUE SHIELD-CO
WI410046659OtherRAILROAD MEDICARE-MEDFORD
WI1271670001OtherDMERC-COLBY GROUP
WI2616OtherLICENSE
WI38596900Medicaid
WI391229699015OtherBLUE CROSS BLUE SHIELD-ME
WI0474980001OtherDMERC-MEDFORD GROUP
WI38715100Medicaid
WI38715300Medicaid
WI74812OtherSECURITY HEALTH PLAN-COLB
WI74813OtherSECURITY HEALTH PLAN-MEDF
WI74813OtherSECURITY HEALTH PLAN-MEDF