Provider Demographics
NPI:1356516801
Name:ROBERT E. BALDWIN
Entity type:Organization
Organization Name:ROBERT E. BALDWIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-752-6110
Mailing Address - Street 1:1097 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2215
Mailing Address - Country:US
Mailing Address - Phone:435-752-6110
Mailing Address - Fax:
Practice Address - Street 1:1097 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2215
Practice Address - Country:US
Practice Address - Phone:435-752-6110
Practice Address - Fax:435-752-1935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT08-00959332H00000X
UT112533-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529085657021Medicaid
UT990002180002Medicaid
UT000090607Medicare PIN
UT990002180002Medicaid