Provider Demographics
NPI:1922018886
Name:BALDWIN, ROBERT E
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 N 200 E STE 195
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7574
Mailing Address - Country:US
Mailing Address - Phone:435-752-6110
Mailing Address - Fax:435-752-1935
Practice Address - Street 1:1451 N 200 E STE 195
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7574
Practice Address - Country:US
Practice Address - Phone:435-752-6110
Practice Address - Fax:435-752-1935
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT06-00959156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT990002180002Medicaid
UT0713160001Medicare NSC
UT000090607Medicare ID - Type UnspecifiedMEDICARE B